Nancss  »  MONOXI  »T»  t 

CHICAGO 


Presented  by 
David  B.  Bosworth,   D.   0. 


COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


MANUAL    OF    GYNECOLOGY. 


MANUAL 


OF 


G  Y  NECOLOGY 


B  E  R  R  Y    HART, 


F.R.C./.E.,    F.R.S.E., 


PRESIDENT  OF  THK    EDINBURGH   OBSTETRICAL/SOCIETY  ;     ^-  -  ^ 
LECTURER    ON    MIDWIFERY    AND    DISEASES    OK    WOMEN,    SFBGEONs'    HAM.,     EDINBURGH  ; 
PHYSICIAN,     ROYAL    MATERNITY    AND    SIMPSON    MEMORIAL     HOSPV/AL,     EDINBURGH; 
ASSISTANT  PHYSICIAN  FOR  DlgE.ltiHO  or.gpMEX,  ROYAL  IXFIRM/RY,  EDIXBITRGH; 


AND 


A.  H.  FREELANU  BARBOUR,  M.A.,  B.Sc., 


LECTURER   ON   MIDWIFERY   AND   DISEASES   OF   WOMEN,    SCHOOL   OF   MEDJ1USE,    EDINBURGH  ; 
ASSISTANT    PHYSICIAN,    ROYAL    MATERNITY-  AND    SIMPSON    M 

ASSISTANT   PHYSICIAN   FOR   DISEASES   OF   WOMEN,    ROYAL   INFIRMARY,    EDINBUI 
PHYSICIAN    FOR   DISEASES   OF   WOMEN   TO  THE   COWGATE 

AND  TO   THE    WOMEN'S   DISPENSARY,    EDINBURGH. 


WITH    FOURTEEN    LITHOGRAPHS    AND    FOUR    HUNDRED    WOOOCUT8. 


.C.P.E.,  F.R.S.E., 


FOURTH    ED  I  TIG  N. 


J.    H.    VAIL    &    CO.,    NEW    YORK. 


1891. 


Alt  riiiltt,i  reserved.] 


TO 

OUR    FRIEND    AND    TEACHER, 


ALEXAKDEK    BUSSELL    SIMPSON", 

M.D.,  F.E.S.B., 


PROFESSOR    OF    MIDWIFERY    AND    DISEASES    OF    WOMEN    AND    CHILDREN    IN    THE 
UNIVERSITY    OF    EDINBURGH. 


'/ 
A 


PREFACE   TO   FOURTH   EDITION. 


Edition  has  been  carefully  revised  and  brought  up  to  date, 
and  New  Sections  on  Massage  and  Apostoli's  Method  of  Treat- 
ment have  been  added  without  materially  increasing  the  size  of  the 
Work. 

The  Index  of  Gynecological  Literature  gives  a  convenient  Biblio- 
graphy of  the  important  papers  published  since  the  last  Edition. 

We  have  to  express  our  thanks  to  Mr  J.  A.  Melville,  not  only  for 
his  literary  help  and  the  work  connected  with  the  Indexes,  but  also 
for  the  preparation  of  the  technical  portion  of  the  Section  on  Apostoli's 
Method. 

To  Mr  J.  C.  Webster,  M.B.,  we  are  also  greatly  indebted  for 
valuable  help  afforded  in  preparing  this  Edition  for  press. 

D.  BERRY  HART. 

A.  H.  FREELAND  BARBOUR. 


EDINBURGH,  Feb.  1,  1890. 


PREFACE   TO   FIRST   EDITION. 

IN  writing  this  Manual  we  have  tried  to  keep  before  our  eyes  the 
great  principle  that  the  Anatomy,  Physiology,  and  Pathology  of 
the  Pelvic  Organs  form  the  foundation  of  good  Clinical  work.  As 
students  we  felt  the  want  of  a  text-book  based  on  this  principle  and 
embodying  the  most  recent  views  from  the  various  literatures  instead 
of  giving  those  of  one  school.  This  want  we  have  endeavoured  to 
supply. 

Our  thanks  are  due  to  Professor  Simpson  for  his  kind  advice  in 
matters  of  difficulty :  and  specially  to  Mr  J.  A.  Melville,  for  the  literary 
revision  of  the  text  and  the  preparation  of  the  copious  Table  of  Contents 
and  Indexes. 

Messrs  W.  &  A,  K.  Johnston  have  executed  the  lithographs  with 
their  well-known  accuracy  and  finish :  and  to  Mr  James  Bayne  we  are 
indebted  for  the  care  and  fidelity  with  which  he  has  drawn  on  the  wood 
the  majority  of  the  engravings.  We  have  in  all  cases  acknowledged  the 
source  of  every  illustration  not  specially  prepared  for  this  work.  " 

D.  BERRY   HART. 

A.  H.  FREELAND  BARBOUR. 

EDINBURGH,  July,  1882. 


TABLE    OF    CONTENTS. 


PART     I. 

ANATOMY,  PHYSIOLOGY,  AND  METHODS  OF  EXAMINATION 
OF  THE  FEMALE  PELVIC  ORGANS. 


SECTION  I.  ANATOMY  AND  PHYSIOLOGY  OF  THE  FEMALE  PELVIC 

ORGANS. 


CHAP.  i.     General  Anatomy  of  External  Genitals  and  Contents 

of  Pelvis          .          .          .          .          .          .          .2 

External  Genitals  as  observed  Clinically     .             .  3 
The  Pelvic  Floor  and  Organs  resting  on  it,  con- 
sidered as  a  whole  .....  7 
The  Pelvis  considered  in  detail         ...  8 
Pelvic  Floor  dissected  from  below     .             .  8 
Pelvic  Floor  dissected  from  above      .            .  12 
The  Uterus  and  its  Annexa    ...  14 
Fallopian  Tubes           ....  22 
Ovaries             .....  23 
Vagina              .....  27 

Bladder 30 

Rectum            .....  36 

PerinealBody              .            .            .            .  38 

Peritoneum      .....  39 

Connective  Tissue  of  Pelvis    ...  41 

CHAP.  ii.    The  Sectional  Anatomy  of  the  Female  Pelvis     .          .  44 

Sagittal  Mesial  Section          ....  45 

Sagittal  Lateral  Section         ....  45 

Transverse  or  Horizontal  Section      ...  47 

Coronal  Section          .....  48 

Axial  Coronal  Section  of  Pelvis        ...  49 


xii  CONTENTS. 

I'AGE 

CHAP.  in.     The  Position  of  the  Uterus  and  its  Annexa,  and  the 

Relation  of  the  Super] acent  Viscera   ...  51 

The  Normal  Form  and  Position  of  the  Uterus        .  53 

The  Local  Divisions  of  the  Pelvic-Floor  Peritoneum 
as  viewed  through  the  Pelvic  Brim,  and  the  posi- 
tion of  the  Uterine  Annexa  ...  57 

The  Physiological  Changes  in  the  position  of  the 

Uterus  ......  58 

The  Relation  of  the  Small  Intestine  to  the  Pelvic 

Floor  and  to  the  Uterus  with  its  Annexa  .  59 

CHAP.  iv.      Structural  Anatomy  of  the  Female  Pelvic  Floor       .  60 

In  Sagittal  Mesial  Section    .....  60 

Pubic  Segment           .....  61 

Sacral  Segment          .....  61 

Segments  Contrasted             ....  61 

In  Axial  Coronal  Section      .....  63 

The  entire  Displaceable  Portion       ...  63 

The  entire  Fixed  Portion      ....  63 

Functions  of  the  Female  Pelvic  Floor      ...  64 

Pelvic  Floor  Projection          .....  65 

CHAP.  v.      Bloodvessels  of  the  Pelvis      .....  68 

Arterial  Supply  .....  68 

to  Uterus,  Ovaries,  &c.  ...  68 

to  Perineal  Region  ....  69 

Venous  Supply          .....  70 

Lymphatics  of  the  Pelvis      .....  71 

Lymphatic  Glands     .....  71 

Lymphatic  Vessels     .....  72 

of  External  Genitals            ...  72 

of  Vagina  and  Cervix  Uteri            .            .  72 

of  Uterus      .....  72 

Relation  between  Glands  and  Vessels         .            .  73 

Nerves  of  the  Pelvis    ......  73 

Spinal.            ......  73 

Sympathetic  ......  73 

Development  of  Pelvic  Organs       ....  74 

CHAP.  vi.      Physics  of  the  Abdomen  and  Pelvis,  with  special 
reference   to   the    Semiprone    and    Genupectoral 

Postures          .......  75 

The  effect  of  Intra-abdominal  Pressure  on  the 

Female  Pelvic  Floor  ....  75 

Results  brought  about  by  change  of  Posture, 

especially  by  the  Genupectoral  Posture  .  .  76 

The  effect  on  Uterine  position  of  Digital  Pressure 

in  the  Vaginal  Fornices  ....  80 


CONTENTS.  xiii 


PAGE 


CHAP.  vn.       Menstruation  and  Ovulation         ....  82 

Preliminary  Considerations  ....  83 

General  Phenomena  of  Menstruation  .  .  83 

Local  Phenomena  of  ,,  .  .  84 

Ovulation        ......  84 

Corpus  Luteum          .....  84 

Source  of  Discharge,  and  Changes  in  the  Uterine 

Mucous  Membrane  85 


SECTION  II.  PHYSICAL  EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

CHAP.  YIII.     External  Abdominal  Examination          ...  90 

Inspection  of  External  Genitals    ....  94 

Vaginal  Examination           .....  94 

Bimanual  or  Abdomino-Vaginal  Examination           .  96 

Other  Varieties  of  Abdominal  Examination    .          .  99 

CHAP.  ix.       Examination  per  Rectum    .....  101 

Simple  Rectal,  Abdomiiio-Rectal  and  Abdomino- 

Recto-Vaginal  .....  101 

Simon's  Method  of  passing  the  Hand  into  the 

Rectum  ......  103 

CHAP.  x.        TheVolsella 104 

Description  of  Instrument     .... 
Methods  of  Use          ...  .104 

Mechanism  of  Displacement  it  causes          .             .  105 

Uses  in  Diagnosis       .....  105 

in  Treatment     .....  106 

Contra-indications      .....  106 

Sims'  Tenaculum        .....  107 

CHAP.  xi.       Vaginal  Specula          ......  108 

Spatular  Speculum — the  Sims           .            .            .  108 

Tubular  Speculum— the  Fergusson  .            .            .  Ill 
Bivalve  Speculum — the  Neugebauer             .         •  .  - 

—the  Cusco          ...  112 

Uses  and  comparative  value  of  the  various  Specula  114 

CHAP.  xn.     The  Uterine  Sound    ......  115 

Nature             ......  115 

Preliminaries  to  its  use ;  centra-indications             .  116 

Method  of  Use 117 

Employment  for  Diagnosis    ....  121 
„              Treatment  ....  122 
Dangers  attending  its  use      .... 
Sound  combined  with  Bimanual 
Relation  of  Sound  to  Bimanual  and  Rectal  Ex- 
amination   .                         ....  123 


xiv  CONTENTS. 

PAGE 

CHAP.  xin.     Tents  and  other  Uterine  Dilators         .          .          .  125 

Tents  .......  125 

Material  ......  125 

Purposes  for  which  used  .  .  .  126 

Preliminaries  to  and  method  of  use  .  .  127 

Dangers  in  use  and  centra-indications  .  .  129 

Hard  Rubber  Dilators— Tait's,  Hanks',  Hegar's     .  130 

CHAP.  xiv.      The  Curette     .......  132 

Varieties 132 

Cases  in  which  useful             ....  132 

Method  of  Use           .....  133 

Cautions  and  Dangers            ....  133 

Relation  of  Posture  to  Examination  and  Treatment  133 

CHAP.  xv.       Instruments     .......  135 

Knives             ......  135 

Scissors  ...... 

Needles           ......  136 

Sutures           ......  137 

Vaginal  Syringes  and  Douches  ;  Uterine  douche    .  137 

Cautery           .....  140 

Anaesthetics    ......  140 

Action  of  Chloroform  ....  140 

Uses  of  Chloroform     ....  142 

Method  of  administration       .            .            .  143 

Dangers            .....  144 

Cocaine             .....  145 

CHAP.  xvi.      Relation  of  Micro-Organisms  to  Gynecology  .          .  146 

Antiseptics       .......  147 

Activity  of  various  antiseptics           .            .            .  148 

Directions  for  use  in  operations        .            .             .  150 


PART     II. 
DISEASES   OF   THE  FEMALE   PELVIC  ORGANS. 

SECTION   III.   THE  PERITONEUM  AND   CONNECTIVE  TISSUE. 

PAGE 

CHAP.  xvn.     Pelvic  Peritonitis  and  Pelvic  Cellulitis  (Parametritis)  156 

Preliminary  considerations    ....  157 

Pelvic  Peritonitis      ......  157 

Pathological  Anatomy  and  Varieties            .            .  158 

Etiology          ......  158 

Symptoms  and  Physical  Signs           .            .            .  160 


CONTENTS.  xv 

PAGE 

CHAP.    xvn.     Pelvic  Peritonitis — continued. 

Differential  Diagnosis            ....  161 

Course  and  Results     .....  161 

Prognosis         ......  162 

Treatment  of  Acute   .....  163 

Prophylactic     .            .            .  163 

General             .            .            .  163 

Local     .            -  v        •            .  165 

Chronic            ....  166 

Tubercular  Peritonitis            ....  166 

Malignant  Peritonitis             ....  167 

Pelvic  Cellulitis  (Parametritis)  ....  167 

Pathological  Anatomy  and  Varieties            .            .  168 

Etiology           ......  168 

Symptoms       ......  169 

Physical  Signs             .....  169 

Differential  Diagnosis  between  Pelvic  Peritonitis 

and  Cellulitis          .....  170 

Course  and  Results    .....  171 

Prognosis         ......  171 

Treatment       ......  171 

Effects  on  Uterus  of  Pelvic  Peritonitis  and  Cellu- 
litis      172 

Displacements  caused  by  Pelvic  Peritonitis              .  173 

Pelvic  Cellulitis    .            .  173 

Parametritis  Chronica  Atrophicans     .          .          .  174 

Circumscripta              .....  174 

Diffusa            ......  175 

Reflex  Disturbances  in           ....  176 

CHAP.  xvin.     Pelvic  Hseruatocele  and  Hsematoma    ...  177 

Preliminary  Considerations   ....  177 

Terminology    ......  178 

Nature  of  Pelvic  Ha;matocele            .            .            .  178 

Pathological  Anatomy           ....  178 

Etiology  :  Sources  of  Hzemorrhage  and  Varieties   .  181 

Symptoms       ......  184 

Physical  Signs            .            .            .            .            .  184 

Diagnosis  and  Differential  Diagnosi              .            .  185 

Course  and  Results    .....  185 

Prognosis         ......  185 

Treatment       ......  185 

At  onset  of  Haemorrhage        .             .            .  185 

After  Suppuration  has  occurred         .            .  186 

New   Growths   in    Peritoneum    and    Connective 

Tissue  (Broad  and  Round  Ligaments)      .          .  187 

Tumours  of  Broad  Ligament             .             .            .  187 

Hydrocele  of  Round  Ligament          .            .            .  187 

Tumours  of  the  Round  Ligament     .             .            .  188 

Echinococci  in  Pelvic  Organs            .            .            .  188 

Tumours  of  Pelvic  Connective  Tissue  189 


CONTENTS. 


SECTION  IV.  AFFECTIONS  OF  THE  FALLOPIAN  TUBES  AND  OVARIES. 

PAGE 

CHAP.  xix.        Affections  of  the  Fallopian  Tube         ...  192 

Abnormalities  .....  193 

Stricture  and  Occlusion  of  the  Tubes  .  .  194 

Patent  Condition  of  the  Tubes          .  .  .  194 

Inflammatory  Conditions  of  the  Tubes— Salpingitis  195 

Pathology  and  Varieties         .  .  195 

Hydrosalpinx  or  Hydrops  Tub*        .  .  .  196 

Pyosalpinx      ......  197 

Haematosalpinx  .....  198 

New  Formations :  Tubo-ovarian  Cysts         .  .  199 

Affections  of  the  Parovarium  199 


CHAP.  xx.         Malformations  of  Ovary    .          .          .          .          .  201 

Ovaritis           .......  202 

Pathological  Anatomy  .... 

Etiology          ...... 

Symptoms  and  Physical  Signs 

Differential  Diagnosis  .... 

Progress  and  Results ..... 

Treatment       ...... 

Periovaritis     .......  204 

Displacements  of  the  Ovary — Hernia.          .          .  204 

Etiology          ......  205 

Diagnosis  and  Differential  Diagnosis            .            .  205 

Treatment       ......  205 

Prolapsus        .......  205 

Pathological  Anatomy            ....  205 

Etiology          ......  206 

Symptoms       ......  206 

Physical  Signs             .....  206 

Treatment       .  206 


CHAP.  xxi.        Operations  for  Removal  of  Fallopian  Tubes  and 

Ovaries .208 

Oophorectomy — Battey's  Operation    ...  208 

Nomenclature             .....  209 

Nature  and  Aims        .....  209 

Indications  and  Results         ....  209 

Methods— Vaginal      .....  210 

Abdominal             ....  211 

Conclusions     ......  212 

Removal  of  Uterine  Appendages — Tait's  Opera- 
tion   .  212 


CONTENTS.  xvii 

.  PAGE 

CHAP.  xxii.       Pathology  of  Ovarian  Tumours  ....  214 

Preliminaries  .            .                         ...  215 

Mode  of  Origin  of  Ovarian  Cysts      .            .            .  216 

Varieties  of  Ovarian  Cyst      ....  219 

Naked-eye  Anatomy   ....  219 

Microscopic  Anatomy ....  221 

Nature  of  Ovarian  Fluid        ....  222 

Solid  Ovarian  Tumours          ....  223 

Non-Malignant            .....  223 

Malignant        ......  224 

Parovarian  Cysts        .....  225 

Other  Broad-ligament  Cysts  ....  226 

CHAP,  xxiii.     Diagnosis  of  Ovarian  Tumours  ....  229 

When  Small  (Pelvic  in  position)       .            .            .  229 

Lateral  to  Uterus         ....  229 

Posterior  to  Uterus      ....  230 

When  Large,  Multilocular,  and  Pediculated  (chiefly 

Abdominal  in  position)       ....  231 

Symptoms        .....  231 

Physical  Signs              ....  231 

Differential  Diagnosis              .            .            .  233 

When  Large  and  Extra-peritoneal  (often  Papillo- 

matous)        ......  234 

Diagnosis  of  Adhesions          ....  235 

Co-existence  of  Pregnancy  and  Ovarian  Tumour    .  235 

CHAP.  xxiv.      Operative  Treatment  of  Ovarian  Tumours  .          .  236 

Ovariotomy     .......  237 

Vaginal  method          .....  237 

Abdominal  method     .....  237 

Requisites         .....  238 

Preliminaries    .....  239 

The  Incision     .....  239 

Evacuation  of  Cyst      ....  240 

Drawing  out  of  the  Cyst  from  Abdomen       .  240 

Securing  of  the  Pedicle           .            .            .  241 

Treatment  of  Adhesions  and  Bleeding           .  243 

Peritoneal  Toilette       ....  244 

Closure  of  Wound       ....  244 

Drainage           .            .            .                         .  244 

Dressing  of  Wound      ....  244 

After-Treatment :  Treatment  of  Complications  245 
Abdominal  Method  when  the  Tumour  is  Papillo- 

matous  and  Extra-peritoneal         .            .            .  245 

Enucleation      .....  245 

Relation  of  Listerism  to  Ovariotomy            .            .  246- 

Ovariotomy  when  Pregnancy  is  present       .            .  246 

Contra-indications  to  Ovariotomy     .            .            .  247 

Course  and  result  of  Ovarian  Tumours  when  left 

alone ........  247 

Adhesions        ......  247 

Torsion  of  Pedicle                                .            .            .  248 


xviii  CONTENTS. 

SECTION  V.  AFFECTIONS  OF  THE  UTERUS. 

PAGE 

Periods  during  which   Morbid   Conditions  of   the 

Uterus  arise            .....  251 

CHAP.  xxv.       Malformations  of  the  Uterus      ....  253 

Relations  of  Malformations  to  Development            .  253 

Pathology 254 

Etiology  and  Classification    ....  259 

Symptoms       ......  260 

Diagnosis        .            .            .            .            .            .  261 

Prognosis         ......  264 

Treatment       .            .            .            .            .            .  264 

CHAP.  xxvi.      Small   Os   Externum ;     Rigidity,    Stenosis,    and 

Atresia  of  Cervix  ......  265 

Etiology  and  Pathology          ....  265 

Symptoms       ......  266 

Diagnosis         ......  269 

Prognosis         ......  269 

Treatment       ......  269 

Dilatation    '     .            .            .            .            .  269 

Division            ......  270 

CHAP.  xxvu.    Atrophy  of  the  Cervix  and  Uterus      ...  274 

Superinvolution  of  the  Uterus    ....  275 

Pathology        ......  275 

Etiology          ......  275 

Symptoms       ......  277 

Diagnosis        ......  277 

Prognosis         ......  277 

Treatment       ......  277 

CHAP,  xxvin.   Hypertrophy  of  the  Cervix  :  Amputation     .          .  279 

Forms  of  Hypertrophy  of  the  whole  Uterus             .  279 

Two  forms  of  Hypertrophy  of  the  Cervix    .            .  279 

Hypertrophy  of  the  Cervix — Vaginal  Portion       .  279 

Pathology       ......  279 

Etiology           ......  280 

Symptoms       ......  280 

Diagnosis        ......  280 

Treatment — Amputation       ....  281 

With  Scissors  or  Knife            .            .            .  281 

"With  Ecraseur  or  Cautery      .                    '    .  285 

Hypertrophy  of  the  Cervix — Supra-vaginal  portion  286 

Treatment      ......  288 

•CHAP.  xxix.      Laceration  of  the  Cervix  and  its  Consequences     .  291 

Introductory  ......  291 

Pathology        ......  292 

Etiology           ...            .            .            .            .  293 

Symptoms       ......  294 

Diagnosis         ......  295 

Treatment       .            .            .            .            .            .  296 

Emmet's  Operation     ....  297 


CONTENTS.  xix 

PAGE 

CHAP.  xxx.       Chronic  Cervical  Catarrh  .....  302 

Pathology        ......  302 

Etiology 307 

Symptoms       .            .            .             .            .            .  308 

Physical  Signs            .....  308 

Diagnosis  and  Differential  Diagnosis            .            .  309 

Prognosis         ......  310 

Treatment       .             .            .            .            .            .  311 

CHAP.  xxxi.      Endometritis  .......  315 

Pathology 315 

Etiology          ......  321 

Symptoms  of  Acute  Endometritis  .  .  .  322 

of  Chronic  Endometritis             .             .  322 

Physical  Signs  of  Acute  Endometritis          .            .  323 

of  Chronic  Endometritis       .             .  324 

Diagnosis :  Differential  Diagnosis    .             .            .  324 

Prognosis        ......  325 

Treatment  of  Acute  Endometritis  .  .  .  325 

of  Chronic  Endometritis              .            .  325 

CHAP,  xxxii.     Acute  Metritis         ......  331 

Pathology       ......  331 

Etiology          ......  331 

Symptoms       ......  332 

Physical  Signs             .....  332 

Progress  and  Termination     ....  332 

Diagnosis        ......  332 

Prognosis        ......  333 

Treatment       ......  333 

Chronic  Metritis     ......  333 

Pathology       .  .  .  .  .  .334 

Etiology          ......  336 

Symptoms      ......  337 

Physical  Signs,  Diagnosis      ....  338 

Differential  Diagnosis            ....  338 

Treatment      ......  339 

CHAP,  xxxin.    Displacements  of  the  Uterus     ....  342 

Preliminaries ......  342 

Definitions      ......  344 

Etiology          ......  345 

Frequency       ......  346 

Symptoms       ......  346 

Physical  Examination            ....  346 

Treatment      ......  347 

Anteflexion     .......  347 

Pathology       .                        ....  347 

Etiology          ......  349 

Symptoms       ......  350 

Obstruction       and       Congestion       theories       of 

Dysmenorrhcea       .....  351 

Physical  Diagnosis     .....  353 


xx  CONTENTS. 

PAGE 

CHAP.  xxxm.    Displacements  of  the  Uterus — (continued.} 

Differential  Diagnosis            ....  354 

Prognosis        ......  355 

Treatment      ......  355 

Anteversion  .......  355 

Pathology       ......  356 

Etiology          ......  357 

Symptoms      ......  357 

Diagnosis        ......  357 

Treatment       ......  358 

Retroversion .......  360 

Pathology  and  Etiology        ....  360 

Symptoms       ......  361 

Diagnosis        ......  361 

Treatment      ......  362 

Retroflexion  =  Retroversion  +  Retroflexion  .          .  362 

Pathology       ......  362 

Etiology          ......  364 

Symptoms      ......  365 

Diagnosis        ......  367 

Differential  Diagnosis            ....  369 

Prognosis        ......  370 

Treatment       ......  371 

Replacement  by  Bimanual     .            .            .  371 

with  the  Sound              .            .  373 

by  Genupectoral  Posture          .  374 

Retaining  the  replaced  Uterus  by  Pessaries  .  375 

by  Operation  382 

CHAP,  xxxiv.     Inversion  of  the  Uterus  .....  384 

Pathology       ......  384 

Etiology  and  Frequency        ....  388 

Symptoms      ......  389 

Diagnosis        ......  390 

Differential  Diagnosis            ....  392 

Course  and  results  of  Chronic  Inversion      .             .  393 

Prognosis        ......  394 

Treatment  ......  394 

Reposition  .....  394 

with  the  hand  alone  or  aided  .  395 

by  continuous  slight  elastic  pressure  398 

Amputation     .....  399 

CHAP.  xxxv.      Tumours  of  the  Uterus    .....  402 

Fibroid  Tumours    ......  402 

Pathology      .......  403 

Situation        ......  403 

Structure        ......  403 

Mode  of  Growth,  Varieties    ....  405 

Changes  in  the  Uterus           ....  409 

Degenerative  Changes            ....  411 

Fibroid  Tumours  of  the  Cervix         .            .            .  412 

Etiology 413 


CONTENTS.  xxi 

PAGE 

CHAP,  xxxvi.     Fibroid  Tumours  of  the  Uterus — (continued]        .  416 

Symptoms      .......  416 

Menorrhagia,  Irregular  Hemorrhages          .             .  416 

Painful  Menstruation             ....  417 

Sensations  due  to  size  and  weight  of  Tumour          .  418 

Pressure  Symptoms    .....  418 

Sterility  and  Abortion            ....  418 

Progress  and  results         .....  419 

Physical  Signs  :  Differential  Diagnosis        .          .  420 

Of  small  Fibroid  Tumours    ....  420 

Of  large  Fibroid  Tumours      ....  422 

Prognosis       .......  424 


CHAP,  xxxvir.    Fibroid  Tumours  of  the  Uterus — (continued]     .  425 

Medical  Treatment  .....  425 

Treatment  by  Electricity          ....  427 

Surgical  Treatment          .....  429 

Removal  through  the  Vagina  .  .  .  429 

Removal  through  Abdominal  Walls  by  Laparotomy  430 
Subserous    pediculated  tumours :    intraperitoneal 

treatment             .            .            .            .    •  431 
Tumours  growing  between  layers  of  Broad  Liga- 
ment or  into  Cellular  Tissue  :  Enucleation       .  431 
Tumours  growing  within  substance  of  wall              .  431 
Enucleation      .....  431 
Hysterectomy .....  432 
The  opening      ....  432 
Extraction  of  tumour  .             .            .  432 
Treatment  of  stump     .             .            .  433 
Intraperitoneal  .             .            .  433 
Extra-peritoneal             .            .  434 
Removal  of  Ovaries  or  of  Uterine  Appendages       .  442 

Summary  as  to  Operative  Treatment          .          .  442 


CHAP,  xxxvin.  Fibro-Cystic  Tumour  of  the  Uterus 

Pathology 

Symptoms 

Diagnosis :  Differential  Diagnosis 

Treatment 


443 

443 
445 
445 
446 


CHAP,  xxxix. 


Polypi  of  the  Uterus 

Varieties 

Symptoms 

Diagnosis 

Differential  Diagnosis 

Prognosis 

Treatment 


447 

447 

453 
454 

456 
457 

458 


xxii  CONTENTS. 

PAGE 

CHAP.  XL.             Carcinoma  Uteri  (of  Cervix)  ....  460 

Pathology  .......  461 

Classification ......  461 

Origin              .      ,      .            .            .            .            .  461 

Position          ......  464 

Progress          .......  46.") 

Extension  to  neighbouring  Organs   .             .            .  466 

Etiology      .......  469 

General  predisposing  Causes             .            .            .  471 

Local  predisposing  Causes     ....  471 

CHAP.  XLI.            Carcinoma  Uteri  (of  Cervix) — (continued}           .  474 

Symptoms  .......  474 

Local  Symptoms  .....  474 

Haemorrhage  .....  474 

Offensive  discharge  ....  474 

Pain  ......  475 

General  Symptoms    .....  476 

Diagnosis    ....... 

Differential  Diagnosis  .... 

Prognosis    ....... 

Causes  of  death          ..... 

CHAP.  XLII.           Carcinoma  Uteri  (of  Cervix) — (continued)          .  483 

Introductory  ......  483 

Treatment  of  Symptoms         ....  484 

Haemorrhage  ......  484 

Offensive  discharge    .....  485 

Pain    .......  485 

General  Treatment    .....  485 

Treatment  of  the  Disease       ....  486 

Principles  of  Treatment        ....  486 

Application  of  Caustics          ....  487 

Scraping  out  of  diseased  tissue          .            .            .  487 

Amputation  of  the  Cervix     ....  488 

Ecraseur  or  Galvano-cautery .            .            .  488 

Knife  and  Scissors       ....  491 

Vaginal  Amputation     .            .            .  491 

Supra-vaginal  Excision             .            .  491 

Amputation  followed  by  caustics       .            .  493 

Excision  of  the  whole  Uterus            .            .            .  494 

By  Abdominal  Incision  (Freund's  method)  .  494 

Through  the  Vagina    ....  495 

Comparison    of    Amputation     of     Cervix     with 

Extirpation  of  Uterus        ....  497 
Comparison  between  Cancer  of  the  Uterus  and  the 

disease  elsewhere    .....  499 

CHAP.  XLIII.          Carcinoma  of  the  Body  of  the  Uterus       .          .  500 

Pathology  and  Etiology         ....  500 

Symptoms  and  Diagnosis       ....  501 

Treatment  502 


CONTENTS.  xxiii 

PAGE 

CHAP.  XLIV.       Sarcoma  Uteri       ^.          .          ...          .          .  503 

Pathology       ......  503 

Etiology  and  Frequency        ....  507 

Symptoms       ......  508 

Diagnosis        ......  508 

Prognosis        .            .            .             .            .            .  510 

Treatment  510 


SECTION  VI.   AFFECTIONS  OF  THE  VAGINA. 

CHAP.  XLV.        Atresia  Vaginae       ......  512 

Pathology       ......  512 

Atresia  Hyrnenalis      ....  512 

Atresia  Vaginalis         ....  513 

Etiology          ......  513 

Symptoms       ......  516 

Diagnosis        ......  516 

Prognosis        ......  518 

Treatment      ......  519 

Dangers  of  Operation              .            .            .  519 

Operation  for  Imperforate  Hymen    .          "  .  520 

for  Atresia  of  the  Vagina              .  521 

for  Atresia  of  the  Cervix  .            .  522 

Atresia  of  one  half  of  a  Septate  Uterus  and  Vagina  523 

CHAP.  XLVI.       Vaginitis        .......  525 

Nature  and  Varieties             .            .            .            .  525 

Pathology       ......  525 

Etiology 527 

Symptoms       ......  528 

Diagnosis         ......  528 

Treatment       ......  529 

Vaginismus    .......  530 

Etiology          ......  530 

Symptoms  and  Diagnosis       ....  531 

Treatment      ......  531 

Sims'  Operation          ....  532 

Tumours  of  the  Vagina  .          ....  533 

Cysts  .......  533 

Fibroid  Tumours        .....  535 

Carcinoma       ......  535 

Sarcoma          ......  536 

Tuberculosis    .  536 


SECTION  VII.   AFFECTIONS  OF  THE  VULVA  AND  PELVIC  FLOOR. 

CHAP.  XLVII.      The  Vulva :  Malformations       ....          540 

Development  ......  540 

Hermaphroditism       .....  540 

True     ......  542 

False    .  543 


xxiv  CONTENTS. 

PAGE 

CHAP.  XLVII.      The  Vulva  :  Malformations — continued. 

Inflammation  of  the  Vulva  (Vulvitis)           .          .  544 

Pruritus  Vulva-          .....  545 

Eruptions  on  the  Vulva         ....  547 

Tumours  of  the  Vulva      ....  547 

Cysts  of  Bartholinian  Glands            .            .            .  547 

Elephantiasis ......  548 

Neuroma         ......  54!) 

Fibroma           ......  549 

Lipoma           ......  549 

Carcinoma       ......  549 

Lupus .......  550 

Kraurosis  or  Atrophy             ....  551 

Pudendal  Hernia        .....  551 

Varix  .......  551 

Hsematoma     ......  551 

External  Haemorrhage            ....  552 

CHAP.  XLVIII.    Rupture  of  the  Perineum          ....  553 

Preliminaries  and  Nomenclature       .             .            .  553 

Pathology  and  Varieties        ....  554 

Etiology           ......  555 

Significance     ......  555 

Treatment      ......  556 

Prophylactic    .....  556 

Operative — immediate             .            .             .  557 

deferred    ....  557 

for  restoration   of  function 

of  sphincter  ani  .            .  558 

for  rupture  of  perineum       .  562 

CHAP.  XLIX.       Displacements  of  the  Pelvic  Floor      .          .          .  563 

Preliminaries  ......  563 

Undue  Yielding  or  Bulge       ....  564 

Prolapsus  Uteri          .....  565 

Definition         .....  565 

Preliminaries   .....  565 

Etiology            .....  565 

Nature.            .....  566 

Symptoms  and  Physical  Signs           .            .  567 

Mechanism       .....  567 

Summary  of  Displacement  in  Prolapsus        .  569 
Diagnosis  and  Differential  Diagnosis             .  56!  ( 
Treatment  by  Pessaries          .            .            .  570 
Treatment  by  Operation         .            .            .  573 
Preliminary  considerations  as  to  Opera- 
tive Technique          .            .            .  574 
Repair  of  Sacral  Segment  by  Perine- 
orrhaphy,  etc.            .            .            .  574 

Operations    that    aim    at    narrowing 

Vaginal  Walls  (Elytrorrhaphy)       .  576 

Shortening  Round  Ligaments .            .  577 

Vaginal  Enterocele          .....  578 


CONTENTS.  xxv 
SECTION  VIII.   DISTURBANCES  OF  MENSTRUAL  FUNCTION. 

PAGE 

CHAP.  L.            Amenorrhoea .......  582 

Causes,  Local  and  Constitutional     .            .            .  582 

Symptoms      ......  582 

Treatment       ......  583 

Menorrhagia .......  584 

Causes,  Local  and  Constitutional     .            .            .  584 

Treatment      ......  584 

Dysmenorrhcea        ......  585 

Varieties         ......  586 

Treatment      ......  588 

SECTION  IX.   DISTURBANCES  OF  REPRODUCTIVE  FUNCTION. 

CHAP.  LI.          Sterility         .......  591 

Relative          ......  592 

Absolute         ......  592 

Etiology          ......  593 

General  Causes            ....  593 

Local  Causes    .....  593 

Treatment      ......  588 

SECTION  X.   AFFECTIONS  OF  BLADDER  AND  RECTUM. 

CHAP.  LIT.         The  Bladder 596 

Anatomy  and  Physiology  ....  596 

Methods  of  Exploring  the  Urethra  .  .  .  599 
Methods  of  Exploring  the  Bladder  by  Catheter  and 

Sound          ......  599 

Methods  of  Exploring  the  Bladder  by  Finger  and 

Speculum     ......  600 

Methods  of  Exploring  the  Bladder  by  Catheterisa- 

tion  of  Ureter  .....  603 
Methods  of  Exploring  the  Bladder  by  Electric 

Endoscope  ......  604 

CHAP.  LIU.        Affections  of  Urethra  and  Bladder     .          .          .  605 

Malformations         ......  605 

Diseases  of  the  Urethra  .          .          .          .          .  605 

Displacements            .....  605 

Neoplasms ;  Urethral  Caruncle         .            .  606 

Urethritis        .....  607 

Dilatation  and  Stricture        ....  607 

Diseases  of  the  Bladder    .....  607 

Displacements             .....  607 

Cystocele        .....  608 

Neoplasms      .....  608 

Cystitis 609 

Calculi  and  other  Foreign  Bodies     .             .  612 

Functional  Diseases  .                         ...  613 


xxvi  CONTENTS. 

PAGE 

CHAP.  LIV.         Vesico-vaginal  Fistula      .....  615 

Pathological  Anatomy  and  Varieties           .            .  615 

Etiology          ......  618 

Symptoms      ......  619 

Diagnosis        ......  619 

Prognosis        ......  620 

Treatment      ......  621 

Essentials         .....  621 

Operation — Preparatory         .            .            .  623 

Paring  of  edges    .            .            .  624 

Adaptation  of  edges  with  sutures  627 

After-treatment           ....  632 

Obliteration  by  Cauterisation             .            .  634 

Closure  of  the  Vagina  :  Kolpokleisis             .  635 

CHAP.  LV.          The  Rectum  .......  637 

Physiology      ......  637 

Examination  ......  639 

Diseases          ......  639 

Displacements  of                     .            .            .  639 

Fissure  of  the  Anus    ....  640 

Piles 642 

Functional  Disturbance  of  Rectum — Constipation  643 

Coccygodynia          .          .          .          .          .          .  644 


APPENDIX. 

Abdominal  Section       ........  645 

Preliminaries .........  645 

Antiseptics     .........  646 

The  Abdominal  Incision        .......  647 

Exploration  of  Abdomen  and  Pelvis  and  Removal  of  Tumours      .            .  648 

Possible  Accidents  during  Laparotomy         .....  651 

Peritoneal  Toilette ;  Closure  of  "Wound       .....  652 

Electricity  in  Gynecology  :  The  Apostoli  Method  of  Treatment .  652 

Introductory  .........  652 

History            .........  653 

Note  on  Electrical  Terms  used          ......  653 

Units  of  Measurement        ......  655 

Action  of  different  Currents  and  Poles         .....  657 

Action  of  the  Galvanic  Current         .....  657 

Action  of  the  Faradic  Current           .....  659 

Apparatus  and  Instruments  .......  659 

The  Current :  its  strength,  duration,  and  frequency  of  operation             .  660 

Pathological  conditions  in  which  Electricity  is  used  in  Gynecology           .  661 

Results           .........  661 

Systematic  Treatment  of  Nerve  Prostration     ....  662 

Seclusion        .........  662 

Absolute  rest  in  bed  .            .......  663 

Systematic  extra-feeding      .......  663 

Use  of  Massage  and  Electricity        ......  663 


CONTEXTS.  xxvii 

PAGE 

Hysteria    ..........  664 

Hystero-epilepsy           ........  666 

Massage     ..........  667 

Relation  of  Gonorrhoea  to  Diseases  of  Women ....  669 

Case-Taking        ........  671 

Sources  of  Gynecological  Literature        .....  675 

Index  of  Recent  Gynecological  Literature        ....  679 


CLASSIFIED    LIST   OF    ILLUSTRATIONS. 


To  facilitate  study,  we  have  grouped  the  illustrations  under  the  following  heads. 


Anatomy — naked  eye 
Sectional  anatomy. 
Anatomy — m  icr  oscopic. 
Pathology — naked  eye 
Pathology — microscopic. 


Charts  of  etiology. 
Gynecological  examination. 
Instruments. 
Operations. 


ANATOMY-NAKED  EYE. 
PLATE  IV.  Surface  view  of  abdomen  and  thorax  . 

,,      VI.  Distribution  of  ovarian,  uterine  and  vaginal 


arteries 

Fig.  Page 

1  External  genitals ....  4 

2  External  genitals  in  section .         .  5 

3  Hymen  of  virgin  with  vertical  slit  6 

4  Hymen  of  virgin  with  oval  opening  6 

5  Crescentic  hymen          ...  6 

6  Outlet  of  bony  pelvis    ...  8 

7  Dissection  of  perineal  region         .  9 

8  Diagram  of  perineal  muscles         .  10 

9  Muscles  of  clitoris  and  bulb .         .  11 

10  Oblique  coronal  section  through 

external  genitals      ...  12 

11  Dissection  of  pelvis       .         .         .13 

12  Levator  ani  and  coccygeus    .         .  14 

13  Virgin  uterus,  from  front  and  in 

section 15 

14  Multiparous    uterus,   from  front 

and  in  section    ....  15 

15  Diagram  of  divisions  of  cervix      .  17 

16  Coronal  section  of  uterus      .         .  18 
20  Fallopian  tube,  ovary  and  parovarium  22 

23  Vagina  on  vertical  section    .         .  26 

24  Anterior  vaginal  wall  and  multi- 

parous  cervix  ....  27 

25  Diagram  of  vertical  mesial  section 

of  pelvis        ....  28 

26  Horizontal  section  of  pelvic  floor 

at  pelvic  outlet  ...  29 

29  Urethral  glands  of  Skene  .  .  31 

31  Course  of  the  ureters  ...  33 
34aThe  rectum  inflated,  showing 

sphincters        ....  36 


at  p.  59 

facing  p.  69 

Fig.  Page 

47  Schultze's  diagram  of  position  of 

uterus 53 

50  Contents  of  female  pelvis  viewed 

through  pelvic  brim         .         .       56 

51  Uterus  seen  through  brim,  with 

bladder  distended    ...       57 

52  Diagram   of  position  of  uterus, 

according    to     distension    of 

bladder 58 

54,  56  Diagrams  of  pelvic- floor  pro- 
jection     .         .         .         .          65, 67 

57  Venous    supply    of    uterus  and 

vagina 70 

58  Diagram  of  intra-abdominal  pres- 

sure           76 

59  Outline  of  figure  in  genupectoral 

posture 77 

61,  62  Diagrams  of  uterus  before  and 

after  menstruation  ...  86 
122  Diagram  of  structures  in  broad 

ligament 199 

159  Nulliparous  os  uteri    .         .         .     271 

160  Multiparous  os  uteri  .         .         .     271 
325  Sacral    segment    of    the    pelvic 

floor 555 

348  Bladder  in  systole  .  .  .597 
359  Normal  relations  of  the  cervix, 

the  ureters,  and  the  urethra  .  617 
394  Direction  of  rectum  and  of  anus 

in  relation  to  intra-abdominal 

pressure 638 


SECTIONAL  ANATOMY   OF   PELVIS. 

PLATE   I.    Position  of  uterus  and  ovaries           .             .  facing  p.  44 

„      II.    Coronal  sections  of  left  half  of  pelvis             .  ,,          46 

,,    III.    Axial  coronal  sections  of  pelvis         .  ,,48 

„       V.    Coronal  section  of  female  cadaver — frozen   .  .  at  p.  59 

Fig.  Page         Fig.  Page 

32  Vertical  mesial  section,  showing 

Y-shape  of  bladder — frozen     .       34 

33  Vertical   section   of  pelvis,    with 

bladder  contracted — frozen      .       35 
341  Coronal  section  through  anus       .       36 


36  Vertical  mesial  section   showing 

peritoneum — frozen .         .         38,  39 

37  Vertical  mesial  section,  with  blad- 

der contracted,  showing  peri- 
toneum— frozen        .        .        38, 39 


CLASSIFIED   LIST  OF  ILLUSTRATIONS. 


XXIX 


Fig.  Page 

38  Vertical  mesial  section,  with  ute- 

rus drawn  back,  showing  peri- 
toneum— spirit  hardened .        38,  39 

39  Vertical  mesial  section  with  peri- 

toneum   dipping    abnormally 
deep — frozen    .         .         .         38, 39 

40  Vertical  mesial  section,  at  end  of 

pregnancy — frozen    .         .         38,  39 

41  Vertical    mesial    section,    during 

parturition — frozen  .         .        38,  39 

42  Vertical  mesial  section,  with  blad- 

der distended — frozen      .         38,  39 

43  Lateral    sagittal    section  —  spirit 

hardened          ....       46 

44  Transverse    section    at    level    of 

hip-joints — frozen    ...       47 

45  Coronal  section  of  pelvis — frozen        48 


Fig.  Page 

46  Transverse  section  of  pelvis  in 

line  of  pyriform  muscles .         .       57 

48  Vertical     mesial    section    with 

bladder  distended    ...       54 

49  Vertical     mesial    section    with 

bladder  contracted — frozen  .  55 
53  Vertical  mesial  section,  during 

parturition — frozen  .  .  62 
60  Vertical  mesial  section  of  pelvis  in 

genupectoral  posture — frozen  .       79 

280  Vertical  mesial  section  of  pelvis 

from  a  case  of  carcinoma  uteri 
spirit  hardened  .  .  .  467 

281  Vertical  mesial  section  of  pel- 

vis from  a  case  of  carci- 
noma uteri  et  vaginae — spirit 
hardened  .  468 


ANATOMY-MICROSCOPIC. 

PLATE  X.    Section  of  Ovary  and  Wolffian  body  of  a  foetal 

lamb          .  ...     facing  p.  225 

„        „    Connective  tissue  sprouting  up  and  surround- 
ing the  germ  epithelium    .  .  ,,          „ 


Fig.  Page 

17  Course    of    glands    of     mucous 

membrane  of  uterus         .         .  19 

18  Vertical  section  through  mucous 

membrane  of  uterus         .         .  19 

19  Vertical  section  through  mucous 

membrane  of  cervix         .         .  20 

21  Section  of  ovary  of  cat          .         .  24 

22  Section  of  human  ovary        .         .  24 


Fig.  Page 

27  Section  of  posterior  wall  of  blad- 

der and  anterior  of  vagina       .       29 

28  Transverse  section  of  urethra       .       31 
30  Epithelial     cells     from    vesical 

mucous  membrane  ...       32 
35  Perpendicular     section     through 

end  of  rectum  ....       37 
63  Mucous  membrane  of  menstruat- 
ing uterus        ....       87 


PATHOLOGY-NAKED   EYE. 

PLATE  XI.   Diagram  of  mode  of  origin  and  growth  of 

multilocular  and  papillomatous  tumours  .       facing  p.  226 
„    XII.  Figs.  1  and  2,  Erosion   and  Laceration  of 

Cervix  as  seen  in  the  Speculum  .  .  „       303 


Fig-  Page 
94  Cervical  canal  dilated  by  a  poly- 
pus   128 

113  Uterus    bound    down    by    peri- 

tonitic  adhesions      .         .         .     161 

114  Uterus  retroverted  and  fixed  with 

adhesions         ....     162 

115  Uterus    drawn  to    one    side  by 

peritonitic  adhesions        .         .     172 

116  Vertical  mesial  section  of  a  hsema- 

toma  felt  as  a  retro-uterine 
tumour  in  case  of  extra-uterine 
gestation 180 


Fig.  Page 

117  Retro-uterine  hsematocele,  with 

pouch  of  Douglas  not  pre- 
viously obliterated  .  .  .  181 

118  Ante-   and    retro-uterine    blood 

effusion 182 

119  Vertical  mesial  section  of  recent 

hsematocele  in  pouch  of 
Douglas  in  case  of  ruptured 
sac  of  extra-uterine  gestation  .  183 

120  Sarcoma    of    Pelvic    connective 

tissue 189 

121  Hydrops  tubse     .         .         .         .194 
128  Multilocular  ovarian  cyst    .         .     219 


CLASSIFIED  LIST  OF  ILLUSTRATIONS. 


Fig.  Page 

129  Papillomatous  cyst  from  hilum 

of  ovary 220 

133  Myoma  of  ovary ....  223 
137  Simple  broad  ligament  cyst  .  226 
143,  144  Rudimentary  uterus  .  254,  255 

145  Uterus  bipartitus        .         .         .     255 

146  Uterus  didelphys        .         .         .256 

147  Uterus  unicornis         .         .         .     256 

148  Uterus  bicornis  ....     257 

149  Uterus  septus     ....     257 

150  Infantile  uterus  ....     258 

151  Primary  atrophy  of  uterus .        .     258 

152  Foetation  in  detached  horn   of 

uterus 262 

153  Uterus  septus,  puerperal    .         .     263 

154  Normal  and  pin-hole  os  in  specu- 

lum  265 

155  Conical  vaginal  portion      .        .     266 
164  Uterus  and  ovaries  from  a  case 

of  superinvolution   .         .         .     277 
165,  166  Hypertrophied  vaginal  por- 
tion of  cervix  .        .        .     280,  281 

174  Hypertrophy     of    intermediate 

portion  of  cervix      .         .         .     286 

175  Hypertrophy  of    supra  -  vaginal 

portion  of  cervix      .         .         .     287 

176  Hypertrophy    of    whole    uterus 

secondary  to  prolapsus    .         .     288 

178  Single  laceration  of  cervix  .         .     292 

179  Multiple  or  stellate  laceration  of 

cervix      .....     293 

200  Diagrammatic  scheme  of  flexions    344 

201  Diagrammatic    scheme    of    ver- 

sions        ....  345 

202  Anteflexion  with  stenosis  at  os 

externum         ....     348 

203  Diagram  to  show  anteflexion  pro- 

duced by  cicatrisation  of  utero- 
sacral  ligaments       .         .         .     349 

204  Myoma  of  anterior  wall      .        .     354 

209  Uterus   retroverted    and  bound 

back  by  peritonitic  adhesions  .     360 

210  Extreme  retroflexion  of  uterus  .     362 

211  Congenital  retroflexion       .         .     364 

226  Inversion  of  uterus     .         .         .     385 

227  Inversion  of  uterus+inversion  of 

vagina,  caused  by  a  small  sub- 
mucous  fibroid          .         .         .     386 

228  Inversion  of  uterus     .         .         .     388 

241  Section  of  a  large  fibroid  tumour, 

fibres  round  several  centres     .     404 

242  Section  of  a  fibroid  tumour,  show- 

ing wavy  bundles  of   fibrous 
tissue 405 

243  Section  of  a  fibroid  tumour,  show- 

ing spaces  between  bundles  of 
fibrous  tissue   ....     405 

244  Pediculated  sub-peritonealfibroid 

tumour 406 

245  Uterus    with    elongated    cavity 

due    to    presence    of    several 
fibroids 407 

246  Interstitial  fibroid  tumour .         .     408 

247  Submucous  fibroid  tumour  pro- 

jecting into  uterine  cavity       .     409 

248  Pediculated  submucous  fibroid  in 

process  of  extrusion         .         .     410 

249  Cervical  polypus  having  appar- 

rently  two  pedicles  .        .         .     413 


Fig.  Page 

251  Uterus  containing  large  fibroid 

tumour 417 

252  Case  of  two-and-a-half  months' 

pregnancy  associated  with  two 
large  fibroids   ....     421 

265  Large    three-lobed  fibroid  from 

the  fundus       ....     444 

266  Fibrous    polypus    laid    open    to 

show  its  identity  in  structure 
with  a  fibroid  tumour      .         .     448 

267  Intra-uterine  submucous  fibroid 

becoming  vaginal     .         .         .     449 

268  Submucous    fibroid    which    has 

come    to    be    wholly    in    the 
vagina 450 

269  Group  of  mucous  polypi  growing 

in  the  cervix  uteri   .         .         .     451 

271  Non-malignant  papilloma  of  cer- 

vix   452 

272  Pediculated  submucous  fibroid   .     454 

273  Submucous  fibroid  which  simu- 

lated Inversion        .         .         .     456 
276  Carcinomatous  nodule         .         .     464 
279  Carcinoma  of  cervix  uteri  pro- 
ducing fistula  ....     467 
281  Vertical  mesial  section  of  pelvis 

in  carcinoma  vaginae  et  uteri  .  468 
284  Cauliflower  excrescence  growing 

from  cervix  uteri     .         .         .     477 

286  Carcinoma  of  the  cervix  leading 

to  occlusion  of  os  uteri    .         .     481 

287  Mode  of  the  spreading  of  carci- 

noma        486 

295  Uterus  extirpated  for  cancer  of 

body 500 

296  Carcinoma  of  the  body  of  the 

uterus 501 

297  Sarcoma  uteri  with  tumours  in 

vagina 504 

299  Section  of  sarcoma  uteri,  showing 

fibroid  nodules         .         .         .     505 

300  Sarcoma  uteri  invading  Fallopian 

tubes 506 

303  Atresia  vaginse,  seen  from  behind    513 

304  Case  of  double  atresia         .         .     514 

305  Atresia  hymenalis       .         .         .     517 

306  Atresia  vagiiice — lower  third       .     517 

307  Atresia  of  cervix  at  os  externum    518 

308  Atresia  of  cervix  at  os  internum    518 
311  Atresia  in  a  septate  uterus          .     523 
317  to  321   Normal  development  of 

external  organs  of  generation .  541 
322,  323  Spurious  hermaphroditism  .  542 
324  Abscess  of  the  Bartholinian 

gland 548 

326  Central  rupture  of  the  perineum  556 
332  Hernial  nature  of  prolapsus  uteri  566 

345  Posterior  vaginal  enterocele        .     579 

346  Dysmenorrhosal  membrane  laid 
open 588 

353  Caruncle  at  urethral  orifice         .     606 

355  Large  stone  extracted  by  vaginal 

lithotomy         .         .         .         .612 

356  Chief  varieties  of  urinary  fistula    616 
357,  358  Deep  and  superficial  vesico- 

vaginal  fistulse  .  .  .  616 
360  Relation  of  peritoneum  to  a 

fistula 618 

395  Rectocele  .  ...  640 


CLASSIFIED   LIST  OF  ILLUSTRATIONS. 


PATHOLOGY -MICROSCOPIC. 

PLATES  IX.  [  Foulis'  cells,  from  ascitic  fluid  in  malignant  )  facing  p.  217 
and  X.  j  tumour  of  ovary  .  .  .  j  „  p.  224 

PLATE  XII.  Fig.  3,  Section  of  cervix  with  simple  erosion  „  p.  303 
PLATE  XIII.  Mucous  Membrane  of  Uterus  in  Eiido- 

metritis  .  .  .  .  ,,  p.  316 

PLATE  XIV.  Microscopic  Sections  of  Sarcoma  of  Vagina, 

and  of  Epithelioma  of  Clitoris  and  Labia        at      p.  536 


Fig.  Page 

124  Cellular  bodies — the    source   of 

ovarian  cysts   ....  216 

125  Diseased  blood-vessels  in  ovary  .  217 

126  Epithelial  tubes — the  source  of 

ovarian  cysts   ....  218 

127  Colloid  degeneration  of  ovarian 

stroina 218 

130  Papillae  of  ovarian  cyst  wall        .  220 

131  Round-celled  sarcoma  from  der- 

inoid  cyst         ....  221 

132  Cells  from  ovarian  fluid      .         .  222 

134  Cancer  of  ovary  .         .         .         .223 

135  Spindle -celled  sarcoma  of  ovary  .  224 

136  Alveolar  sarcoma  of  ovary  .         .  224 

184  Papillary  form  of  erosion    .         .  303 

185  Follicular  form  of  erosion  .         .  304 

186  True  iilceration  of  the  cervix      .  305 

187  Healing  of  catarrhal  patch  .         .  310 

192  Hypertrophied    glands    in    en- 

dometritis        ....  316 

193  Mucous   membrane  in    endome- 

tritis  fungosa  ....  317 

194  Dilated  blood-vessels  in  endome- 

tritis                                            .  318 


Fig.  Page 

195  Granulation  from    endometritis 

composed  of  embryonic  tissue  .     319 
199  Section     of    uterine    tissue    in 

chronic  metritis 
270  Section  of  a  mucous  polypus  of 

the  cervix         .... 
275  Cancer  of  the  vaginal  portion 
275*Cancer  of  the  cervix  proper 

277  Section  of  a  portion  of  cervix 

uteri  with  carcinomatous  no- 
dule           

278  Section  of  a  flat  cancroid  of  the 

cervix 

285  Scraping  from  carcinoma  of  the 

cervix  ..... 
298  Section  of  mucous  membrane  in 

sarcoma  ..... 

301  Scraping  from  a  fibroid  tumour . 

302  Scraping  from    a   spindle-celled 

sarcoma 

312  Granular  vaginitis — acute  form  . 

313  Granular  vaginitis — chronic  form 

314  Colpitis  emphysematosa     . 
316  Section  of  vaginal  cyst 


335 

451 
463 
463 


465 
466 
479 

505 
509 

509 
526 
526 
526 
534 


CHARTS    OF   ETIOLOGY. 


Fig.  Page 

221  Influence  of  age  on  development 

of  fibroid  tumour  .  .  .  414 
282  Influence  of  sex  on  development 

of  carcinoma    ....     471 


Fig.  Page 

283  Influence  of  age  on  development 

of  carcinoma    .  .     473 


GYNECOLOGICAL   EXAMINATION. 

PLATE  VII.  Female  cadaver  in  semiprone  posture  .     facing  p.  109 

,,  VIII.  Female  cadaver  in  semiprone  posture,  with 
Sims'  speculum  passed  and  uterus  drawn 
down  with  volsella  .  .  .  ,,  p.  110 


Fig. 


Page 
96,97 
98 


(54,  6;")  Right  hand  in  Bimanual 

66  Left  hand  in  Bimanual 

67  Displacement  of  pelvic  floor  and 

abdominal  wall  in  Bimanual   .       99 

68  Right    hand  in  abdomino  -  recto- 

vaginal  examination  .  .  102 
71  Uterus  drawn  down  by  volsella  .  107 
77  Method  of  holding  Sims'  speculum  110 

85  First  stage  of  passing  sound          .     117 

86  Second  stage   of  passing  sound, 

in  retroverted  uterus       .         .     118 

87  Proper  contrasted  with  improper 

method  of  turning  the  sound  .     119 


Fig.  Page 

88  Second  stage  of  passing  sound 

with  uterus  to  the  front .         .     119 

89  Sound  arrested  in  anteflexion     .     120 

90  Sound  combined  with  Bimanual    122 
95  Introduction  of  tangle  tents        .     129 

138  Area    of     dulness    in    ovarian 

tumour  and  ascites  .  .  .  232 
204  Diagnosis  between  fibroid  and 

anteflexion  ....  3o4 
212  Diagnosis  of  retroflexion  by 

Bimanual  ....  368 
230,  231,  232  Diagnosis  of  inversion 

and  polypus  in  vagina      .         .     391 


CLASSIFIED   LIST  OF  ILLUSTRATIONS. 


Fig.  Page 

233,  234  Diagnosis  of  partial  inver- 
sion and  intra-uterine  polypus    392 
235  Uterine  polypus + In  version         .     393 
253  Sound  used  to  detect  pediculated 

submucous  fibroid    .  .     423 


Fig.  Page 

305,  308  Diagnosis  of  various  forms 

of  atresia  .  .  .  517,  518 
352  Catheterisation  of  ureters  .  .  603 
396  Use  of  anal  speculum  .  .  641 
397-399  Diagrams  for  case-taking  673,  675 


INSTRUMENTS. 


Fig.  Page 

55  Callipers   for    measuring   pelvic 

floor  projection         ...       66 

69  A.  R.  Simpson's  volsella     .         .     105 

70  Hart's  volsella     .         .         .         .106 
72  Sims'  Tenaculum         .         .         .107 
73,  74  Sims'  speculum      .         .         .     109 

75  Bozeman's  speculum   .         .         .     109 

76  Battey's  speculum       .         .         .     109 
78  Fergusson's  speculum          .         .     Ill 
79,  80  Neugebauer's  speculum          .     112 

81  Barnes'  crescent  speculum  .         .     113 

82  Cusco's  speculum         .         .         .     113 

83  Sir  J.  Y.  Simpson's  sound  .         .     115 

84  A.  R.  Simpson's  sound        .         .116 

91  Laminaria  tents  before  and  after 

expansion         ....     126 

92  Tupelo   tents    before  and  after 

expansion         ....     126 

93  Tupelo  tent  extended          .         .     127 

96  Tait's  dilators      ....     130 

97  Hanks'  dilator     .         .         .         .131 
97AHegar's  dilator  .         .         .         .131 

98  Recamier's  curette      .         .         .     132 

99  Simon's  scoop      ....     133 

100  Thomas'    curette,    modified    by 

A.  R.  Simpson         .         .         .133 

101  Martin's  curette .         .         .         .133 

102  Bozeman's  scissors       .         .         .     135 

103  Kuchenmeister's  scissors     .         .     166 

104  Hart's  scissors     ....     136 

105  Emmet's  needles          .         .         .137 

106  Needle-holder     .         .         .         .137 

107  Higginson's  syringe     .         .         .     137 
108,  109  Vaginal  douche    .         .         .138 

110  Fritsch's    catheter  for  washing 

out  the  interior  of  the  uterus  .     139 

111  Cones  for  cautery        .         .         .     141 

112  Chloroform  drop-cork          .         .     143 

139  Spencer  Well's  trocar          .         .     240 

140  Ordinary  trocar  ....     240 

141  Nelaton's  forceps         .         .         .     241 

142  Spencer  Wells'  clamp          .         .     241 

156  Schultze's  dilator         .         .         .270 

157  Marion  Sims'  dilator  .         .         .     270 

158  Sir  J.  Y.  Simpson's  metrotome  .     271 

162  Glass  plug  for  cervical  canal       .     272 

163  Conical  excision  of  cervix   .         .     273 
1 73  Rake  for  removing  sutures  .         .     285 
198  Sir     J.     Y.     Simpson's    porte- 

caustique          ....     328 
205  Greenhalgh's  intra-uterine  stem      355 


Page 
358 
359 
375 
375 
375 
378 


207  Graily  Hewitt's  cradle-pessary 

208  Thomas'  anteversion  pessary 

216  Hodge  pessary    .... 

217  Albert  Smith  Pessary 

218  Side  view  of  Albert  Smith  pessary 

221  Hodge  pessary  insituad  naturam 

222  Position  and  support  of  pessary 

illustrated        .... 

223  Position  and  action  of  pessary  in 

vagina 

224  Schultze's  pessary 

225  Meadow 's  compound  stem  pessary 
254  A.  R.  Simpson's  nail-curette  for 

fibroids 

258  Pean's  curved  needle  for  ligatur- 

ing pedicle  of  fibroids 

259  Cintrat's  serre-noeud  . 

260  Keith's    clamp    for    pedicle    of 

fibroids     ..... 

261  Kaltenbach's  needle  for  elastic 

ligature    .         .         .         . 
274  Forceps  with  catch  for  mucous 
polypi 

288  Simon  s  sharp  spoon   . 

289  Chain  ecraseur    .... 

309  Perforated  glass  plug  used  after 

operation  for  atresia  vaginas    . 

310  Breisky's  instruments  for  operat- 

ing in  atresia  with  retention    . 
315  Henderson's  vaginal  spatulfe 

333  Greenhalgh's  pessary  with  trans- 

verse bars         .... 

334  Ring  pessary  with  diaphragm 

335  Simple  elastic  ring  pessary 

336  Ring  pessary  in  situ    . 

337  Zwanck's  pessary 

349*,  350  Simon's  urethral  specula   . 
351  Skene's  urethral  specula     . 
354  Skene  -  Goodman    self -retaining 

catheter  

364-66  Knives  for  operating  on  fistulas 
367  Sponge-holder  .... 
368,  369  Sir  J.  Y.  Simpson's  tubular 

needle  and  method  of  use 
372-73  Bozeman's  fork  and  method 

of  use  ....  626-627 
377  Bozeman's  suture  adjuster .  .  629 
378-79  Coghill's  wire  -  twister  and 

method  of  use  ....  629 
389,  390  Sims'  stationary  catheter  .  632 
396  Anal  speculum  ....  641 


379 

380 
381 
381 

430 

435 
436 

437 

438 

458 
488 
489 

521 

522 
528 

570 
~>70 
570 
571 
571 
601 
602 

611 

024 
624 

625 


OPERATIONS. 


Fig.  Page 

123  Staffordshire  knot       .         .         .211 
161  Bilateral  division  of  cervix  with 

Kuchenmeister's  scissors          .     272 
163  Conical  excision  of  cervix    .         .     273 
167  Sims'    method    of    passing    the 
sutures    after    amputation    of 
cervix  .     282 


Fig.  Page 

168  Marckwald's  method  of  splitting 

and   stitching    the    cervix    in 
amputation      ....     283 

169  A.  R.  Simpson's  method  of  ampu- 

tating the  cervix      .         .         .     284 
170,  171  Introduction  of  sutures  in 

amputation  of  cervix       .         .     284 


CLASSIFIED   LIST  OF  ILLUSTRATIONS. 


XXXlll 


Fig.  Page 

172  Hegar's  method  of  passing  the 

sutures 285 

177  Amputation  of  hypertrophied 

cervix  in  proplasus  uteri .         .     289 

180  Emmet's     operation  —  denuded 

surface     .....     298 

181  Denuded    surface    as  made    by 

Emmet 298 

182  Emmet's    operation  —  introduc- 

tion of  sutures          .         .         .     299 

183  Emmet's    operation  —  tying    of 

sutures     .....     300 

188  Forceps  dressed  with  cotton  wad- 

ding for  applications  to  cervical 
canal 311 

189  Barnes'  speculum  for  introducing 

vaginal  tampons      .         .         .     311 
190,  191  Schrreder's  excision  of  cer- 
vical mucous  membrane  .         .     313 
19lAj\fartin's  method  of  excising  the 
mucous     membrane     of     the 
cervix       .....     314 

196  Sound  dressed  with  wadding  for 

intra-uterine  applications        .     326 

197  Curetting  of  uterus     ...     327 
206  Sims'  division  of  cervix,  lines  of 

incision    .....     356 

213  RepositioTi  of  retroflexed  uterus 

by  finger  in  rectum  .         .         .     370 

214  Reposition  of  retroverted  uterus 

with  the  sound         .         .         .     372 

215  Reposition  of  xiterus  with  vol- 

sella,  and  finger  in  rectum         .     374 

219  Introduction  of  pessary       .         .     376 

220  Pessary  carried  on  by  finger        .     377 
229  Drawing-down  of  inverted  uterus 

with  tape  -  noose  and  lines 
of  incision  for  Barnes'  opera- 
tion  390 

236  Reposition    of    inverted    iiterus 

with  the  hand          .         .         .     395 

237  Reposition    of    inverted    uterus 

with  White's  repositor    .         .     396 

238  Reposition    of    inverted    uterus 

with  finger  in  bladder  and 
rectum 397 

239  Emmet's    method    of    retaining 

partially  replaced  uterus  with 
sutures  .....     397 

240  Cup  with  stem  for  gradual  reduc- 

tion of  inversion  .  .  .  399 
255  Martin's  operation  for  enuclea- 

tion  of  fibroid   from  wall  of 

uterus  .....  431 
256,  257  Supra  -  vaginal  amputation 

of  uterus  for  fibroid  tumour  433,  434 

262  Extra-peritoneal  treatment,  with 

elastic  ligature,  of  pedicle  of 
fibroids 438 

263  Mode    of    sewing-up    stump    in 

extra-peritoneal  treatment  of 

pedicle 439 

264«,  2646  Mode  of  suturing  walls 

and  peritoneum  round  stump  .  440 
290  Chain  ecraseur  applied  to  cervix 

in  amputation ....     490 


Fig.  Page 

291  Schroeder's    supravaginal  ampu- 

tation of  cervix        .         .         .     492 

292  Sims'  method  of  removing  carci- 

nomatous  cervix  .  .  .  493 
293,  294  Vaginal  extirpation  of  the 

uterus     ....       495,  496 
327,  328,  329  A.  R.  Simpson's  opera- 
tion for  complete  rupture  of 
the  perineum          .         .       558,  559 
330aLawson  Tait's  operation  for  tear 

of  perineum  ....  560 
3306,  330cOperation  for  rupture  into 

anus  .....  560 
330^Coronal  section  through  anus  .  560 
331  Emmet's  operation  for  ruptured 

perineum          ....     562 
335  Introduction  of  ring  pessary        .     570 
338-341  Operation  for  repair  of  peri- 
neum      ....      572-574 

342  Various    forms  of    raw   surface 

made  on  posterior  vaginal  wall 

in  operation  for  prolapsus        .     575 

343  Raw  surface  as  made  by  Martin      576 

344  Raw  surface  on  anterior  vaginal 

wall,  as  made  by  Sims  .  .  577 
349  Emmet's  button-hole  operation 

on  the  urethra          .         .         .     598 

357  Closure  of  superficial  vesico-vagi- 

nal  fistula         ....     616 

358  Closure   of    deep    vesico-vaginal 

fistula 616 

360  Relations  of  peritoneum  to  ex- 

tensive fistula ....     618 

361  Simon's  method  of  paring  edges 

of  fistula 621 

362  Sutures  passed  to  close  fistula    .     623 

363  American  and  German  methods 

of  paring  edges  of  fistula  con- 
trasted      623 

369  Passing  of  thread  with  tubular 

needle 625 

370  Knife    transfixing    edges    of    a 

fistula 626 

371  Fistula  closed  with  sutures         .     626 
372,  373  Fork  used  to  prevent  sutures 

from  cutting  .  .  .  626,  627 
374  Counter  -  pressure  made  with 

blunt  hook  .  .  .  .627 
375-379  Method  of  twisting  sutures  628-629 
376  Mode  of  tying  wire  sutures  .  629 
380-381  Bozeman's  method  of  fixing 

sutures  with  plates  and  shot  .  629 
382,  391  Removal  of  sutures  .  629,  633 
383-384  Closure  of  a  four-cornered 

fistula 630 

385  Anterior  lip  of  cervix  used  to 

close  fistula      ....     630 

386  Anterior  lip  divided  to  close-in 

vertically  a  fistula   .         .         .     631 

387  Obliteration  of  cervical  canal  for 

vesico-uterine  fistula        .         .     631 

388  Operation  for  atresia  urethrae  in 

fistula 632 

392-393  Simon's  operation  for  closure 

of  vagina  :  kolpokleisis  634,  635 
396  Division  of  base  of  an  anal  fissure  641 


PART  I. 


ANATOMY,  PHYSIOLOGY,  AND  METHODS 
OF  EXAMINATION  OF  THE  FEMALE  PELVIC  ORGANS. 

Section  I.  Anatomy  and  Physiology  of  the  Female  Pelvic  Organs. 
,,       II.  Physical  Examination  of  the  Female  Pelvic  Organs. 


SECTION    I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  FEMALE 
PELVIC  ORGANS. 


TN  order  to  give  a  comprehensive  idea  of  the  Anatomy  and  Physiology 
-^  of  the  Female  Pelvic  Organs,  it  will  be  advisable  to  consider  them 
in  the  following  manner. 

CHAPTER  I.  General  Anatomy  of  External  Genitals  and  Contents  of 
Pelvis. 

CHAPTER  II.  The  Sectional  Anatomy  of  the  Female  Pelvis. 

CHAPTER  III.  The  position  of  the  Uterus  and  its  Annexa,  and  the 
relation  of  the  Superjacent  Viscera. 

CHAPTER  IV.  The  Structural  Anatomy  of  the  Pelvic  Floor ;   Pelvic- 
Floor  Projection. 

CHAPTER  V.  The  Blood-vessels,  Lymphatics,  and  Nerves  of  the  Pelvis. 
Development  of  Pelvic  Organs. 

CHAPTER  VI.  Physics  of  the  Abdomen  and  Pelvis,  with  special  refer- 
ence to  the  Semiprone  and  Genupectoral  Postures. 

CHAPTER  VII.  Ovulation  and  Menstruation. 


CHAPTER   I. 

GENERAL   ANATOMY   OF. EXTERNAL   GENITALS 
AND    CONTENTS    OP   PELVIS. 

LITERATURE. 

EXTERNAL  GEXITALS.  Ballantyne—The  Labia  Minora  and  Hymen  :  Edin.  Med.  Jour., 
Nov.  1888,  p.  425.  Budin — Recherches  sur  1'hymen  et  1'orifice  vaginal :  Paris,  1881. 
Garrard — Beitrag  zur  Anatomie  und  Pathologie  der  Kleinen  Labien  :  Ztschrift  fiir 
Geburtshiilfc  and  Gynakologie,  Bd.  X.,  Hft.  1.  Matthews  Duncan — Papers  on  the 
Female  Perineum  :  Churchill,  London,  1880.  F.  P.  Foster — A  Contribution  to  the 
Topographical  Anatomy  of  the  Uterus  and  its  Surroundings  :  Am.  J.  of  Obst.,  Vol. 
XIII.,  p.  30.  Garrigues — The  Obstetric  Treatment  of  the  Perineum  :  Am.  J.  of 
Obst.,  Vol.  XIII.,  p.  231.  Hart,  D.  Berry— "Note  on  the  Naked-eye  Anatomy 
of  the  Female  External  Genitals  :  Ed.  Med.  Jour.,  1882.  Atlas  of  Female  Pelvic 
Anatomy,  Edinburgh,  1884.  Henle— Handbuch  der  Eingeweidelehre  des  Menschen  : 
Braunschweig,  1866.  Klein — The  External  Genitals  of  the  Male  and  Female,  by 
E.  Klein :  Strieker's  Manual  of  Human  and  Comparative  Histology,  Vol.  II. 
(Syd.  Soc.  Tr.,  1872).  Klein  and  Smith— Atlas  of  Histology  :  Smith,  Elder,  &  Co. 
London,  1880.  Sutton—  On  the  Nature  of  the  Hymen  :  Brit.  Gyn.  Jour.,  1888. 

MUSCLES  OF  PELVIC  FLOOR.  Cunningham — The  Dissector's  Guide ;  Abdomen :  Mac- 
lachlan  &  Stewart,  Edinburgh,  1880.  Doran — A  Dissection  of  the  Muscles  of  the 
Female  Pelvis  and  Perineum :  Lond.  Obst.  Tr.,  1886,  274.  Henle — op.  cit.  Luschka — 
Die  Musculatur  am  Boden  des  weiblichen  Beckens  :  Wien,  1861.  Savage — Female 
Pelvic  Organs,  2d  Edition :  London,  1870.  Turner — An  Introduction  to  Human 
Anatomy  :  A.  &  C.  Black. 

UTERUS,  AND  ANNEXA  ;  ORGAN  OF  ROSENMU'LLER  AND  GARTNER'S  CANALS  ;  VAGINA. 
Barnes — The  Diseases  of  Women ;  London,  1878.  Breisky — Die  Krankheiteii  der 
Vagina  :  Billroth's  Handbuch,  Stuttgart,  1879.  Coe — The  Anatomy  of  the  Female 
Pelvic  Organs  :  Amer.  Syst.  of  Gynecology,  Vol.  I.,  p.  95.  Cruveilhier — Traite 
d'Anatomie  Descriptive  :  Paris,  1871.  Engelmann — The  Mucous  Membrane  of  the 
Uterus:  Am.  J.  of  Obst.,  Vol.  VIII.,  p.  30.  Farre — The  Uterus  and  its  Append- 
ages :  Todd's  Cyclopaedia,  Vol.  V.  Hart — Structural  Anatomy  of  Female  Pelvic 
Floor  :  Maclachlan  &  Stewart,  1880.  Henle  —  op.  cit.  Hennig  —  Der  Katarrh 
der  inneren  weiblichen  Geschlechtstheile  :  Leipzig,  1862.  Kiistner — Das  untere 
Uterinsegment  und  die  Decidua  cervicalis  :  Jena,  ]882.  Munde — Prolapse  of  the 
Ovaries :  American  Gynecological  Transactions,  Vol.  IV.,  1879.  Rainey — On  the 
Structure  and  Use  of  the  Ligamentum  Rotundum  Uteri :  Lond.  Phil.  Tr.,  1880,  p. 
515.  Rieder — Ueber  die  Gartner'schen  (Wolff'schen)  Kanale  beim  menschlichen 
Weibe  :  Virch.  Archiv.  Bd.  96.  (This  paper  gives  literature  and  references  to  papers 
by  Gartner,  Dohrn,  Freund,  and  others.)  Ruge  and  Veil — Zur  Pathologie  der 
Vaginal  Portion  :  Stuttgart,  1878.  Sappey — Traite  d'Anatomie  Descriptive :  Paris, 
1873.  Schroedei — Handbuch  der  Krankheiten  der  weiblichen  Geschlechtsorgane  : 
Leipzig,  1879.  Taylor — Gastro-Hysterectomy,  or  the  Recent  Modification  of  the 
Caesar ean  Section,  by  Dr  Porro  :  American  Journal  of  Medical  Science,  Vol.  LXXX., 
p.  115.  Turnei — op.  cit. 

BLADDER.  H.  J.  Garrigues — Remarks  on  Gastro-Elytrotomy  :  Am.  Gynecol.  Tr.,  Vol. 
III.,  p.  212.  Polk,  W.  M.—  Landmarks  in  the  Operation  of  Laparo-Elytrotomy : 
N.  Y.  Med.  Jour.,  May  1882.  Skene — Diseases  of  the  Bladder  and  Urethra :  New 
York,  1870.  The  Anatomy  and  Pathology  of  Two  Important  Glands  in  the  Female 


EXTERNAL   GENITALS.  3 

Urethra  :  Am.  J.  of  Obst.,  Vol.  XIII.  Winckel — Die  Krankheiten  der  weiblichen 
Harnrohre  und  Blase  :  Billroth's  Handbuch,  Stuttgart,  1877. 

RECTUM.  Braune — Topographisch-anatomischer  Atlas,  Zweite  Auflage  :  Leipzig,  Veit 
and  Co. ,  1872.  Chadivick—The  Function  of  the  Anal  Sphincters  so-called :  Am.  Gyn. 
Tr.,  Vol.  II.,  p.  43.  Hart — Physics  of  Rectum  and  Bladder  :  Edin.  Med.  Jour., 
1882.  Otis — Anatomical  Researches  on  the  Human  Rectum  :  Leipzig,  1887. 
Pirogoff—  Anatome  Topographica  etc.  sectionibus  per  corpus  humanum  congelatum  : 
Petropoli,  1859.  Ruedingei — Topographisch-chirurgische  Anatomie  des  Menschen  : 
IV.  Abtheilung.  Symington — Rectum  and  Anus  :  Jour,  of  Anat.  and  Phys.,  XXIII. 

PERINEAL  BODY — Hart,  Henle,  Savage,  op.  cit.  Ranney — The  Female  Perineum  :  New 
York  Med.  Jour.,  Vol.  XXXVI.,  Nos.  1  and  2.  T.  G.  Thomas— The  Female  Perineum ; 
its  Anatomy,  Physiology,  and  Pathology  :  Am.  J.  of  Obst.,  Vol.  XIII.,  p.  312. 

PERITONEUM  AND  CELLULAR  TISSUE.  Bandl — Die  Krankheiten  der  Tuben,  der  Lagamente, 
und  des  Beckenperitonaums :  Stuttgart,  1879.  Barnes — St.  George's  Hospital  Re- 
ports, Vol.  VII.,  p.  57.  Freund — Anatomische  Lehrmittel  zur  Gynakologie :  Beitrage 
zur  Geburtshulfe  und  Gynakologie.  Herausgegeben  von  der  Gesellschaft  fur 
Geburtshiilfe  in  Berlin,  IV.  Band,  1  Heft.  S.  58.  Guerin — Sur  la  Structure  des 
Ligaments  Larges  :  Comptes  Rendus,  1879, 1364.  Le  Bee — Contribution  a  1'etude  des 
Ligaments  Larges  (au  point  de  vue  de  1'anatomie  et  de  la  pathologic) :  Gaz.  Hebd., 
15  Avril  1881.  Von  Preuschen — Ueber  Cystenbildung  in  der  Vagina  :  Virchow 
Archiv.  Bd.  70.  De  Sinety — Gynecologic  :  Paris,  1880.  Spiegelberg — Remarks  upon 
Exudations  in  the  neighbourhood  of  the  Female  Genital  Canals  :  German  Clinical 
Lectures  (New  Syd.  Soc.  Tr.),  p.  169.  Braune,  Cunningham,  Hart,  Pirogoff, 
op.  cit. 

EXTERNAL    GENITALS   AS    OBSERVED    CLINICALLY. 
UNDER  the  term  external  genitals  are  comprised  the  structures  known  External 
as  Labia  Majora,  Fourchette,  Labia  Minora,  Clitoris  with  its  prepuce, Genitals- 
Vestibule,  and  Fossa  Navicularis.     For  clinical  convenience  the  urethral 
orifice  and  hymen  also  are  described  with  these ;  although  the  urethral 
orifice  belongs  to  the  urinary  system,  and  the  hymen  separates  anatomi- 
cally the  external  genitals  (vulva)  from  the  vagina. 

The  Labia  Majora  (fig.  1,  a)  are  two  thick  folds  of  hair-clad  skin,  Labia 
extending  from  the  symphysis  pubis  backwards  between  the  thighs,  and  •|ora" 
meeting  each  other  nearly  in  the  middle  line  and  about  2.7  cm.  (1  inch) 
in  front  of  the  anus ;  their  blunted  posterior  ends  can  be  seen  most 
distinctly  in  the  foetus.  Each  labium  has  an  outer  and  inner  surface, 
and  consists  of  a  thick  fold  of  skin  enclosing  a  quantity  of  fat,  blood- 
vessels, and  dartos.  Superiorly,  where  they  are  best  developed,  they 
form  by  their  junction — anterior  commissure — the  structure  known  as 
the  mons  veneris  (vide  Plate  IV.) ;  while  posteriorly  they  are  a  mere 
fold  of  skin  known  as  the  Fourchette  or  posterior  commissure.  The  fat 
and  connective  tissue  are  almost  entirely  wanting  at  the  fourchette, 
which  is  not  a  distinct  structure  but  may  be  the  posterior  junction  of 
the  thinned-out  labia  minora  or  labia  majora.  Both  labia  majora  are, 
in  the  adult,  covered  with  crisp  hair  which  is  abundant  over  the  mons 
veneris  and  outer  surface  but  very  much  less  so  on  the  inner. 

The  Labia  Minora  (fig.  1,  b)  are  two  small  oblique  folds  of  skin,  one  Labia 
on  the  inner  surface  of  each  labium  majus.     Posteriorly  each  blends       ora> 
insensibly  with  the  labium  majus  at  about  its  middle,  while  anteriorly 


4  ANATOMY   OF  PELVIS. 

they  converge  and  each  divides  into  two  small  branches — an  upper  and 
a  lower.  The  upper  branches  meet  to  form  the  prepuce  of  the  clitoris 
(fig.  1,  e),  while  the  lower  in  a  similar  way  form  its  suspensory  ligament. 
As  a  rule  the  labia  minora  do  not,  in  the  adult,  project  beyond  the  labia 
majora.  Sebaceous  glands  are  present  on  both  labia.  Microscopically 


FIG.  1. 

EXTERNAL  GENITALS  OF  VIRGIN,  with  Diaphragmatic  Hymen.  The  Labia  Majora  and  Minora  are 
drawn  apart,  and  the  prepuce  drawn  back.  The  cadaver  is  in  the  lithotomy  posture.  (Modified 
from  Sappey.)^ 

a  Labium  majus ;  &  Labium  minvis ;  c  Vestibule  just  above  urethral  orifice ;  d  Glans  clitoridis ; 
f  Praeputium  clitoridis  ;  /Mons  Veneris.  (}) 

the  labia  minora  have  the  structure  of  skin  and  Carrard  has  found  in 
them  Meissner's  corpuscles  which  are  nerve  end-organs  found  only  in 
the  papillae  of  skin.  As  above  stated,  the  labia  minora  may  be  con- 
tinued into  the  fourchette. 

The  Clitoris,  covered  by  its  prepuce,  lies  in  the  middle  line  and  at  the 
apex  of  the  smooth  piece  of  mucous  membrane  known  as  the  vestibule. 
Only  that  part  analogous  to  the  glans  penis  is  seen  (fig.  1,  d).  The 
clitoris  proper  consists  of  two  crura  which  arise  from  the  rami  of  the 


EXTERNAL   GENITALS.  5 

ischium  and  pubes  and  unite  superiorly  to  form  the  body  of  the  clitoris, 
which  lies  beneath  the  mucous  membrane.  The  glans  clitoridis  is  not 
directly  continuous  with  the  body,  but  joins  it  through  the  pars  inter- 
media of  the  bulb  (vide  post,  p.  10). 

The  Vestibule  (fig.  1,  c)  is  a  triangular  smooth  mucous  surface  bounded  Vestibule, 
superiorly  by  the  clitoris,  laterally  by  the  labia  minora,  and  inferiorly  by 
the  upper  margin  of  the  vaginal  orifice.  In  the  middle  line,  at  its  base, 
the  dimple  of  the  urethral  orifice  can  be  distinctly  felt  1  inch  (2 — 2.5  cm.) 
in  front  of  the  fourchette.  Small  depressions  and  mucous  glands  open  on 
its  surface. 

The   Vaginal  Orifice  lies  in  the  middle  line  between  the  base  of  the  Vaginal 

.  r*  *" 

vestibule  and  the  fossa  navicularis.     Its  orifice  is  guarded  by  the  hymen, 

a  thin  fold  of  mucous  membrane  enclosing  some  connective  tissue, 
blood-vessels,  and  nerves  (?).  The  hymen  may  be  crescentic  in  shape, 
attached  to  the  posterior  margin  of  the  vaginal  orifice  and  with  a  free 


Orifice. 


FIG.  2. 

VERTICAL  MESIAL  SECTION  OF  EXTERNAL  GENITALS  (Henle). 

a  Anus  ;  6  Perineal  body ;  c  Vagina ;  d  Urethra  ;  e  Labium  Minus ;  /  Prepuce  of  Clitoris  ;  g  Fossa 
Navicularis,  with  Hymen  in  front  and  Fourchette  behind.  (}) 

edge  towards  the  base  of  the  vestibule  (figs.  2  and  5) ;  or  diaphragmatic, 
attached  all  round  the  vaginal  orifice  but  with  a  small  hole  (figs. 
1  and  4)  or  vertical  slit  (fig.  3)  in  it.  Sometimes  it  is  not  so  perforated, 
constituting  a  pathological  condition. 

The  point  as  to  whether  the  Hymen  belongs  developmentally  to  the  external  genitals 
or  vagina  is  disputed.  Budin  believes  that  the  hymen  is  simply  the  thinned-out  inferior 
margins  of  the  anterior  and  posterior  vaginal  walls.  One  specimen  we  have  examined 
certainly  supports  his  statement  that  the  vaginal  columns  run  on  the  inner  aspect  of  the 
hymen.  Matthews  Duncan  has  pointed  out  the  interesting  fact  that  in  atresia  vagina  the 
hymen  may  be  present,  i.e.  may  be  present  although  the  vaginal  walls  are  absent.  More 
recently  Pozzi  has  'described  cases  of  mal-development  of  the  sexual  organs,  and  brought 
out  some  interesting  facts.  One  case  was  that  of  a  male  hypospadiac  with  external 
genitals  simulating  a  female  type,  i.e.  with  a  pseudo-vulva,  a  distinct  hymen,  and  a 
fourchette.  Pozzi  found  a  ridge  passing  from  the  base  of  the  glans  penis,  encircling  the 
meatus  urinarius  and  becoming  continuous  with  the  hymen  :  this  he  terms  the  male 


6  ANATOMY  OF  PELVIS. 

vestibuLir  band.  In  a  female  with  atresia  vaginse  he  found  a  similar  band  passing  from 
the  clitoris,  surrounding  the  urethral  orifice,  and  blending  with  the  hymen.  He  advances 
the  view  that  the  hymen  is  vulvar  in  its  origin  and  alleges  that  in  women  the  ' '  male 
veatibular  band"  can  be  seen  on  careful  examination.  In  the  hypospadiac  already 
described  this  band  was  the  remnant  of  the  corpus  spowjiosum,  so  that  he  believes  the 
hymen  to  be  the  analogue  of  the  bulb  in  man. 

Recent  papers  by  Ballantyne  and  Button  support  the  view  that  the  hymen  is  vulvar 
in  its  origin.  Ballantyne  has  also  confirmed  Pozzi's  view. 

Fossa  Navicularis. — Normally,  the  inner  aspect  of  the  fourchette  is 
in  contact  with  the  outer  and  lower  surface  of  the  hymen.  When  the 
fourchette  is  pulled  back  by  the  finger,  a  boat-shaped  cavity  is  made — 
the  fossa  navicularis.  Its  posterior  boundary  is,  therefore,  the  inner 
aspect  of  the  fourchette ;  its  anterior  is  the  posterior  aspect  of  the 
hymen.  These  two  are  in  contact  unless  artificially  separated  (fig.  2). 

From  behind  forwards,  in  the  female  ano-vulvar  region  there  lie  in 
the  middle  line  the  following  structures. 

(1.)  Anus. 

(2.)  Skin  over  base  of  Perineal  Body. 

(3.)  Fourchette. 

(4.)  Fossa  Navicularis. 

(5.)  Vaginal  orifice,  with  Hymen  or  its  remains. 

(6.)  Urethral  orifice. 

(7.)  Vestibule. 

(8.)  Clitoris  with  its  prepuce. 
Laterally,  we  have  the  labia  majora  and  minora. 


FIG.  3.  FIG.  4.  FIG.  5. 

HYMEN  OF  VIRGIN,  with  Vertical  Slit.  ({)   HYMEN  with  Oval  Opening.  (})    CRESCENTIC  HYMEN.  (}) 

The  following  points  should  be  carefully  noted.  In  the  nude  erect 
female  only  the  mons  veneris  is  seen,  and  the  labia  majora  and  minora 
lie  in  a  plane  nearly  parallel  to  the  horizon.  The  well-developed  labia 
majora  have  their  inner  surfaces  always  in  contact,  and  are  only  slightly 
separated  by  the  widest  divergence  of  the  knees.  The  labia  minora  are 


PELVIC  FLOOR  AS  A    WHOLE.  1 

always  in  contact,  and  require  to  be  artificially  separated  in  order  to  see 
their  inner  surfaces.  The  fossa  navicularis  only  exists  when  artificially 
opened  up.  Therefore,  to  see  the  external  genitals  fully,  the  labia  must 
be  separated  and  the  prepuce  drawn  back. 

A  line  running  as  follows  separates  mucous  membrane  from  skin. 
Starting  from  the  base  of  the  inner  aspect  of  the  right  labiuni  minus,  it 
passes  doivn  beside  the  base  of  the  outer  aspect  of  the  hymen,  up  along 
the  base  of  the  inner  aspect  of  the  left  labium  minus,  in  beneath  the 
prepuce  of  the  clitoris,  and  down  to  where  it  first  started  from. 

The  vulvar  slit  is  sagittal,  and  lies  in  the  middle  line  between  the  labia 
majora  and  minora. 

The  vaginal  orifice  is  transverse,  only  exists  when  artificially  made,  Hymen, 
and  is  anatomically  defined  by  the  hymen  which  separates  the  external 
genitals  from  the  internal  genitals.  The  sharp  line  between  skin  and 
mucous  membrane  can  be  distinctly  seen  on  the  living  subject.  The 
labia  minora  are  skin,  thin  and  fine,  and  not  mucous  membrane  as  often 
alleged. 

The  following  measurements  by  Foster  are  useful  for  reference  : — 

Tip  of  Coccyx  Anus 

to  Anus.  to  Fourchette. 

Average  distance  in  nulliparae,       .         .        4 '5  cm.      .         .2*7  cm. 
,,  ,,  multipart,     .         .        4 '7  cm.      .         .         2 '5  cm. 

Meatus  urinarius,  2 — 2 '5  cm.  from  fourchette,  in  nulliparae;  2 — 3'1  cm.,  in  women 
who  have  borne  children. 

The  virginal  vaginal  orifice  should  have  the  appearances  shown  at 
figs.  1,  3,  4,  and  5,  and  the  free  edge  of  the  hymen  should  be  intact. 

In  a  healthy  woman  who  has  experienced  complete  coitus,  the  hymen 
is  torn  or  often  only  stretched.  It  admits  two  fingers  without  pain. 
In  a  woman  who  has  borne  full-time  children,  the  vaginal  orifice  is 
always  torn,  although  the  fourchette  and  all  behind  it  may  be  intact. 
The  carunculse  myrtiformes  are  probably  the  remains  of  the  hymen.  In 
addition,  the  passage  of  the  child's  head  may  cause  tears  of  the  posterior 
vaginal  wall,  perineal  body,  or  even  anterior  wall  of  anus. 

THE  PELVIC  FLOOR  AND  ORGANS  RESTING  ON  IT 
CONSIDERED  AS  A  WHOLE. 

The  outlet  of  the  bony  female  pelvis  is  filled  in  by  what  is  generally 
described  as  the  'soft  parts.'  This  term,  however,  should  not  be 
employed,  as  it  is  misleading,  especially  in  scientific  obstetrics.  It  is 
better  named  the  pelvic  floor  or  pelvic  diaphragm. 

The  pelvic  floor  is  a  thick  fleshy  elastic  layer,  dovetailed  all  round  Pelvic 
to   the   bony    pelvic    outlet   (fig.    6).     It   may   be    considered   as   an 
irregularly-edged  segment  of  a  hollow  sphere,  with  an  outer  skin  aspect 
and  an  inner  peritoneal  one.     On  the  outer  skin  aspect  lie  the  external 
genitals  already  described.     On  the  inner  peritoneal  surface  we  have 


8  ANATOMY  OF  PELVIS. 

the  organ  known  as  the  uterus,  and  its  appendages  the  Fallopian  tubes 
and  ovaries.  The  vagina  runs,  in  the  erect  female,  at  an  angle  of  about 
60°  to  the  horizon  from  the  vaginal  orifice  upwards  to  the  mouth  of  the 


FIG.  6. 

BONY  PELVIC  OUTLET,  with  transverse  line  showing  Rectal  and  Urethral  Triangles 
(D.  J.  Cunningham).  (\) 

womb,  as  a  transverse  slit  in  the  pelvic  diaphragm.  In  front  of  the 
vagina  lies  the  bladder,  while  behind  it  the  rectum  is  placed;  these 
structures,  along  with  muscles,  connective  tissue,  blood-vessels,  nerves, 
and  lymphatics,  making  up  the  pelvic  diaphragm. 

Figure  1  shows,  accordingly,  the  pelvic  floor  seen  from  its  convex, 
skin  aspect ;  fig.  50  gives  it  and  the  organs  resting  on  it  as  viewed  from 
its  concave,  peritoneal  side ;  while  fig.  32  displays  it  as  seen  in  sagittal 
mesial  section. 

THE  PELVIS  CONSIDERED  IN  DETAIL. 

PELVIC    FLOOR    DISSECTED    FROM    BELOW. 

If  a  female  cadaver  be  placed  in  the  lithotomy  posture  and  a  trans- 
verse line  drawn  just  in  front  of  the  ischial  tuberosities,  the  perineal 
region  will  be  divided  into  a  posterior  rectal  triangle  and  an  anterior 
urethral  one  (fig.  6).  The  former  contains  the  anus,  the  latter  the 
external  genitals. 

The  fascia  of  the  pelvic  floor  and  its  relations  demand  a  few  words  here. 
(1.)  The  superficial  fascia. 
(2.)  The  deep  layer  of  the  superficial  fascia. 
(3. )  The  triangular  ligament  in  two  layers. 

(1.)  The  superficial  fascia  lies  beneath  the  skin,  and  is  simply  the  continuation  over 
the  pelvic  floor  of  the  general  superficial  fascia  of  the  body. 

(2.)  The  deep  layer  of  the  superficial  fascia  has  the  following  attachments  : — Laterally 
and  above,  it  is  joined  to  the  pubic  arch  ;  while  posteriorly  it  passes  round  the  trans- 


FERINE AL   MUSCLES. 


verse  perineal  muscles  to  join  the  base  of  the  anterior  layer  of  the  triangular  ligament. 
If  air  be  injected  beneath  this  deep  layer,  its  passage  is  limited  by  the  attachments 
given,  and  a  sac  is  made — the  pudendal  sac.  Into  this  sac  an  inguinal  hernia  may  push 
its  way,  and  in  it  the  round  ligaments  of  the  uterus  end. 

(3.)  The  triangular  ligament  consists  of  two  layers  of  fascia,  filling  in  the  pubic  arch. 
They  are  termed  anterior  and  posterior.  The  following  table  may  be  omitted  at  present, 
imtil  the  whole  anatomy  is  mastered. 


Between  skin  and  superficial  fascia. 


Between  deep  layer  of  superficial 
fascia  and  anterior  layer  of  tri- 
angular ligament. 


(  Supfl.  haemorrhoidal  vessels  and  nerves. 
(  Supfl.  perineal  artery  and  nerve. 

Transversus  perinei. 

Bulbo-cavernosus. 

Erector  clitoridis. 

Transverse  perineal  blood-vessels  and  nerves. 

Venous  plexuses. 

Bulbs  of  vagina. 

Pudendal  sacs. 

Dorsal  artery  and  vein  of  clitoris. 


/  Compressor  urethrae. 

Between  the  layers  of  the  triangular  j  Vagina— in  part. 
ligament.  ,  Urethra-in  part. 

(v.  also  p.  11.)  (Pudic  vessels  and  nerves. 

By  suitable  incisions  the  skin  and  superficial  fascia  can  be  removed  Ischiorectal 
around  the  anus,  and  the  ischiorectal  fossa  defined.     This  is  a  small   08sa' 


FIG.  7. 

DISSECTION  OF  PERINEAL  REGION  (Sarape). 

a  is  just  above  Trans  versus  Perinei ;  6  Base  of  Perineal  body  ;  c  Bulbo-cavernosus  ;  d  lies  on 
Levator  Ani  and  in  Ischiorectal  Fossa  ;  e  Erector  Clitoridis  ;  /  Bulb  of  Vagina  ;  g  Bartholinian 
Gland  ;  h  Vestibule  ;  j  Glans  Clitoridis.  (\) 

pyramidal  cavity  on  each  side  of  the  rectum,  bounded  externally  by  the 


10 


ANATOMY  OF  PELVIS. 


Muscles 
beneath 
superficial 
fascia  (deep 
layer). 


Bulbi 

Vaginre. 


obturator  interims  muscle,  internally  by  the  levator  ani.  Its  apex  is 
formed  by  the  junction  of  these  muscles,  while  its  base  is  partially 
closed  in  by  the  transversus  perinei  and  the  edge  of  the  gluteus  maxi- 
mus  muscle  (fig.  7).  If  axial- transverse  sections  of  the  fossa  be  made 
(PI.  II.  fig.  2,  and  PI.  III.  fig.  2),  \ve  see  that  it  is  merely  the  passage  of 
the  subcutaneous  fat  between  the  gluteus  maximus,  levator  ani,  and 
obturator  internus  muscles.  The  gluteus  maximus  forms  the  posterior 
and  inferior  boundary. 

On  transverse  sections  from  before  backwards  it  can  be  noted  that  its  boundaries 
vary.  At  the  level  of  the  ischial  tuberosity  it  is  bounded  as  follows  :  inside,  levator  ani ; 
outside,  lower  half  of  obturator  internus ;  while  the  gluteus  floors  it  in  incompletely. 
About  an  inch  posterior  to  the  tuberosity,  we  find  the  boundaries  change  as  follows  : 
inside,  we  have  still  the  levator  ani ;  outside,  a  small  portion  of  the  obturator  internus  ; 
while  the  gluteus  maximus  floors  it  in  completely.  At  the  posterior  margin  of  the  fossa, 
the  levator  ani  is  the  inner  and  upper  boundary,  the  gluteus  maximus  the  outer  and 
lower,  the  fossa  here  being  quite  below  the  level  of  the  obturator  internus.  If  the  skin 
and  superficial  fascia  be  now  removed  from  the  urethral  triangle,  the  following  muscles, 
etc.,  will  be  exposed  (fig.  7). 

Perineal  muscles. — On  each  side  of  the  vaginal  orifice  three  muscles 
lie,  viz.,  the  bulbo-cavernosus  (fig.  8,  b  c),  erector 
clitoridis  or  ischio-cavernosus  (fig.  8,  e  c),  and  trans- 
versus perinei  (fig.  8,  t  p). 

The  Bulbo-cavernosi  consist  of  two  muscular  slips, 
one  on  each  side  of  the  vaginal  orifice,  which  spring 
behind  from  the  perineal  body  and  pass  round  the 
vaginal  orifice,  partially  covering  the  bulb  and  the 
vagina  (fig.  7,  c).  The  anterior  end  of  each  slip 
splits  into  three  portions  which  end  as  follows : — 
One  passes  to  the  under  surface  of  the  corpus 
cavernosum  of  the  clitoris,  a  second  goes  to  the 

posterior  surface   of  the   bulb,   and  a  third  blends   with  the  mucous 
membrane  between  the  clitoris  and  urethral  orifice  (Henle,  v.  fig.  9). 

The  Erector  Clitwidis  arises  from  the  inside  of  the  ischial  tuberosity 
and  is  inserted  into  the  back  and  sides  of  the  crus  clitoridis  (fig.  9,  e ). 

The  Transversus  Perinei  arises  from  the  ramus  of  the  ischium,  and 
passes  to  the  perineal  body.  It  is  difficult  to  define  practically  in 
dissection  (fig.  7,  a). 

Now  that  these  muscles  have  been  described,  we  are  in  a  position  to 
localise  more  important  structures. 

The  Bulbi  Vaginae,  (corpora  cavernosa  urethrse)  are  small  masses  of 
erectile  tissue  about  the  size  of  a  bean,  lying  one  on  each  side  of  the 
vaginal  orifice  and  partly  under  cover  of  the  bulbo-cavernosus  muscle. 
Each  rests  on  the  triangular  ligament,  and  has  internally  the  mucous 
membrane  of  the  vagina ;  while,  as  already  said,  they  are  partly 
covered  by  the  bulbo-cavernosus  muscle.  Anteriorly  each  blends  with 


PERINEAL   MUSCLES. 


11 


its  fellow,  and  this  pars  intermedia  becomes  continuous  with  the  clitoris 
(fig.  7,/>. 

The  Bartholinian  Glands  lie  one  on  each  side  of  the  vaginal  orifice  Bartho 
close  to  the  posterior  end  of  the  bulb,  and  in  front  of  the  posterior  layer  Q^^S 
of  the  triangular  ligament  (figs.  7,  g,  and  10,  e).     Each  has  a  long  duct 
opening  at  the  sides  of  the  hymen.     Ranney  asserts  that  these  glands 
lie  behind  the  posterior  layer  of  the  triangular  ligament. 

Between  the  lower  one-third  of  the  posterior  wall  of  the  vagina  andPe"neal 


FIG.  9. 

Symphysis  Pubis,  showing  muscles  in  connection  with  Clitoris  and  Bulb.     The  Clitoris,  c,  c",  is 
cut  across  near  its  point,  and  thrown  down  with  the  vestibulary  mucous  membrane  (Henle). 
e  Erector  Clitoridis  ;  /  Bulbo-cavernosus  with  its  three  insertions  ;  d  Branch  to  Dorsal  Vein 
of  Clitoris.  (}) 


the  anterior  wall  of  the  rectum,  is  an  angular  interspace  (fig.  2,  &)  filled 
up  by  the  structure  known  as  the  perineal  body.  This  will  be  more 
fully  described  afterwards.  At  the  present  stage  of  the  dissection  only 
its  base  is  seen,  with  the  following  muscles  taking  origin  from  or  having 
an  insertion  into  it, — sphincter  ani,  transversus  perinei,  bulbo-cavernosus, 
levator  ani  (fig.  7).  Between 

Between  the  layers  of  the  triangular  ligament  lie  the  urethra,  a  portion  layers  of 
of  the  vagina,  compressor  urethrfe,  dorsal  vein  of  the  clitoris,  internal  ligament. 


12  ANATOMY  OF  PELVIS. 

pudic  vessels  and  nerves,  the  artery  to  bulb,  dorsal  nerve  of  clitoris,  and 
Bartholinian  glands  (Cunningham). 

The  dissection  of  the  urethral  triangle  has  now  been  considered  until 
the  bladder  has  been  exposed  as  it  lies  behind  the  pubes,  from  which  it 
is  separated  by  a  considerable  amount  of  loose  fatty  tissue.  In  order 
to  complete  the  consideration,  we  have  now  to  take  up  the  muscles  not 
yet  described,  viz.,  levator  ani,  coccygeus  and  the  obturator  internus. 


FIG.  10. 

OBLIQUE  SECTION,  parallel  to  the  Anterior  Pelvic  Wall  and  through  the  External  Genitals  (Henle). 

a  Vagina ;  6  Urethra  ;  c  Corpns  Cavernosum  Clitoridis,  covered  by  its  Erector  ;  d  Bulbus 
Vaginae  covered  by  Bulbo-cavernosus  Muscle  ;  e  Bartholinian  Gland. 

THE    PELVIC    FLOOR    DISSECTED    FROM    ABOVE. 

The  pelvic  floor  must  now  be  looked  at  from  its  internal  concave  or 
peritoneal  aspect.  If  the  peritoneum  and  connective  tissue  beneath  it, 
with  the  nerves  and  blood-vessels,  be  removed  on  one  side  of  the  pelvis, 
say  the  right,  the  two  muscles  known  as  the  coccygeus  and  levator  ani 
will  be  exposed.  These  spring  from  the  middle  of  the  inner  side  of  the 
true  pelvis  and,  blending  partly  directly  and  partly  indirectly  with  one 
another,  form  what  may  be  termed  the  diaphragmatic  muscles  of  the 
pelvic  floor.  If  looked  at  through  the  pelvic  brim,  they  are  seen  to 
form  on  both  sides  a  concave  arrangement  analogous  to  the  thoracic 
diaphragm  (fig.  11). 

Ooccygeus.  The  Coccygeus  springs  from  the  spine  of  the  ischium  and  is  inserted 
into  the  side  of  the  lower  part  of  the  sacrum,  and  side  and  front  of 
coccyx.  There  are  two  coccygei,  one  on  each  side  (figs.  11  and  12). 

Levator          The  Levator  Ani  has  an  extensive  origin.     It  springs  in  front  from 

*"  the  back  of  the  body  and  horizontal  ramus  of  the  pubes,  from  the  pelvic 

fascia  (white  line)  and  the  spine  of  the  ischium.     From  this  the  muscle 

sweeps  downwards  and  inwards  to  become  attached  in  the  middle  line 

from  before  backwards  as  follows, — to  the  vagina,  the  rectum,  its  fellow 


PELVIC  MUSCLES. 


13 


of  the  opposite  side,  and  finally  to  the  tip  of  the  coccyx  (fig.  12).  The 
pubic  fibres  blend  "with  the  posterior  half  of  the  upper  border  of  the 
sphincter  vaginse  "  (Doran). 

The  levator  ani  can  act  on  the  vagina,  elevating  it,  and  is  also  believed 
to  aid  the  sphincter  ani  (v.  PI.  II.  and  III.). 

The  Obturator  internus  has  the  following  Origin :  deep  surface  of 
obturator  membrane  except  at  its  lowest  part  •  fibrous  arch  completing 
canal  for  obturator  vessels  and  nerves ;  and  surface  of  true  pelvis 
bounded  above  by  iliopectineal  eminence,  posteriorly  by  great  sciatic 
notch,  inferiorly  by  ischial  tuberosity  (vide  PI.  III.).  Its  relations  are  well 


FIG.  11. 

DISSECTION  OF  PELVIS  from  above  (Savage), 
a  Sacrum  ;  6  Urethra  ;  c  Vagina  ;  d  Rectum  ;  e  Levator  Ani ;  /  Coccygeus  ;  g  Obturator  internus.  (J) 

shown  in  axial-transverse  sections  (v.  Chap.  II.  and  PI.  III.).  In  fig.  2, 
PI.  III.,  its  inferior  half  bounds  the  ischiorectal  fossa ;  its  upper  half, 
the  bladder  and  levator  ani.  It  can  also  be  seen  that  it  lies  in  relation 
to  the  broad  ligaments,  i.e.  it  bounds  them  where  the  peritoneal  laminae 
diverge. 


14 


ANATOMY  OF  PELVIS. 


We  have  now  to  take  up  the  consideration  of  the  generative  organs. 
It  is  difficult  to  describe  these  without  alluding  to  structures  not  fully 
considered  until  further  on.  The  student  may,  therefore,  not  entirely 
grasp  some  of  the  points  until  the  whole  anatomy  of  the  organs  has  been 
mastered. 


Corpus 
Uteri. 


FIG.  12. 
LEVATOB  ANI  and  COCCYGEUS  seen  from  without,  after  removal  of  part  of  hip  bone  and  clearing  out 

of  Ischiorectal  Fossa  (Luschka). 
a  Fibres  of  Levator  Ani  on  Vagina  ;  6  Anus,  with  Sphincter.  (J) 

THE    UTERUS    AND    ITS   ANNEXA. 

TheUtems.  The  Uterus  is  a  triangular  body,  with  a  truncated  apex  downwards, 
placed  between  the  bladder  and  rectum,  and  with  the  appearance  seen 
at  figs.  13  A  and  14  B.  In  describing  it  we  take  up  its  external 
appearance,  its  nature  on  section,  and  its  structure  and  relations. 

On  external  examination  we  find  the  parts  known  as  the  body  (fig. 
13,  A,  c),  and  neck  (fig.  13,  A,  a,  b).  Keeping  in  mind  its  description 
as  a  triangle,  we  see  the  neck  occupying  the  apex  and  the  uterine  orifices 
of  the  Fallopian  tubes  at  the  other  two  angles.  Between  the  Fallopian 
tubes  lies  the  fundus  uteri.  The  anterior  surface  of  the  uterus  is 
almost  flat ;  the  posterior  is  convex  at  its  upper  part,  as  is  well  seen  in 
fig.  13,  B.  Where  the  body  passes  into  the  cervix  there  is  a  slight 
depression  noticed  on  the  posterior  surface.  This  corresponds  to  the 
isthmus. 

On  making  a  vertical  mesial  section,  we  observe  that  the  uterus  is  a 
hollow  organ  possessing  a  cavity  with  the  anterior  and  posterior  walls 
in  apposition  (fig.  13,  .5).  In  order  to  see  the  cavity  it  is  advisable  to 
look  at  the  uterus  in  coronal  section,  i.e.,  a  section  which,  passing 
through  the  cavity,  divides  the  uterus  into  an  anterior  and  a  posterior 
half,  as  shown  in  fig.  13,  C,  fig.  14,  A.  This  latter  section  enables  us 
more  fully  to  understand  the  division  of  the  uterus  into  body  proper 


Cavity  of 
Uterus. 


UTERUS  AND   ANNEX  A.  15 

and  cervix,  and  the  division  of  the  uterine  cavity  into  cavity  of  the 


FIG.  13. 

A.  VIRGIN  UTERUS  (front  view)  (Sappey).    The  Appendages  and  Vagina  are  cut  away. 

a  Cervix  (vaginal  portion) ;  6  Isthmus ;  c  Body  ;  a  6  Cervix  proper. 

B.  The  SAME  in  vertical  mesial  section. 

a  is  anterior  surface,  and  lies  just  above  where  peritoneum  passes  on  to  bladder. 

C.  The  SAME  with  cavity  exposed  by  coronal  section. 

e  Os  Extei-num  ;    d  Os  Internum  ;  /  Uterine  Opening  of  Fallopian  Tube,  (jj) 


body  proper  and  cervical  cavity. 


FIG.  14. 

A.  MuLTirARors  UTERUS  in  coronal  saction  to  show  cavity. 

B.  MULTIPABOUS  UTERUS  from  front  (Sappey).  (§) 


16 


ANATOMY  OF  PELVIS. 


Cavity  of  Body. — This  is  a  triangular  slit  in  the  uterus  with  the  apex 
downwards,  and  with  anterior  and  posterior  walls.  At  each  angle  there 
is  an  opening,  viz.,  at  the  lower  angle  we  have  the  os  internum  opening 
into  the  cervical  canal  (fig.  1 3,  C,  d),  and  at  the  upper  angle  the  uterine 
openings  of  the  Fallopian  tubes  (fig.  13,  C,  f).  The  lining  of  the 
cavity  is  known  as  its  mucous  membrane. 

Cavity  of  the  Cervical  Canal. — This  is  spindle-shaped  or  conical  (fig. 
13,  B,  C),  and  has  two  openings,  viz.,  os  internum  above  and  os  externum 
below.  The  former  opens  into  the  uterine  cavity,  the  latter  into  the 
vagina. 

The  Cervix  is  divided  into  two  portions,  the  vaginal  and  the  supra- 
vaginal.  The  vaginal  portion  is  within  the  vagina,  and  appears  as  a 
conical  mass  of  the  size  and  shape  seen  at  fig.  13,  A,  a.  The  os 
externum  is  in  virgins  a  mere  dimple,  and  feels  to  the  examining  finger 
like  the  tip  of  the  nose.  In  women  who  have  borne  children  it  is 
transverse  (fig.  14,  B\  and  in  most  cases  has  its  lips  fissured  more  or 
less  deeply,  and  the  mucous  membrane  of  the  cervical  canal  partially 
everted.  The  supra- vaginal  portion  is  continuous  with  the  body  through 
the  isthmus. 

The  length  of  the  whole  unimpregnated  uterus  is,  speaking  generally, 
about  3  inches;  the  length  of  the  cavity  of  cervix  and  body  about  2^ 
inches. 

Measurements  with  the  sound  on  the  living  female  are  a  little  in 
excess  of  those  obtained  in  sections  on  cadavera,  owing  probably  to  the 
sound's  elongating  the  uterus  somewhat. 


Length  of  uterus     . 
Width    .... 
Thickness 

Vertical  diameter  of  cavity 
Transverse    . .  , , 


Virgin. 
2'35  in. 
1-50  „ 
0-85  „ 

1-80  „ 
0-60  „ 


Nulliparse 
2 '50  in. 
1-55  „ 
0-90  „ 


Length  of  entire  organ  in  young  women        .... 

Do.  body  of  uterus 

Do.  cervix 

Do.  vaginal  portion  of  cervix     .... 

Capacity  of  uterus  in  nulliparse  =  2-3  c.cm.  ;  in  multiparse  3-5  c.cm. 


Mnltiparae. 
270  in. 
1'70  „ 
1-00  „ 

Sappey. 
2-44  in. 
1-24  „ 

Richet. 
5-6  cm. 
3-3-5  „ 
2-3     „ 
•55- '6  „ 
Hennig. 
Sappey. 


Various  authors  divide  the  cervix  uteri  more  minutely  as  follows. 


of  cervix     They  consider  it  as  made  up  of — 


a.  a  vaginal  portion  ; 

b.  an  intermediate  portion  ; 

c.  a  supravaginal  portion. 


(Fig.  15.) 


STRUCTURE  OF   UTERUS.  17 

This  view  is  of  importance  in  relation  to  the  seat  and  extent  of  the 
changes  in  the  size  of  the  uterus  in  prolapsus  uteri. 

The  question  as  to  the  precise  position  of  the  os  internum  in  the  Position  of 
unimpregnated  uterus  is  at  present  much  disputed.      Kiistner,   who  numn  ei 
has   examined   the   point   carefully,   places    the    os   internum   at   the 
narrow  part  where  the  lumen  of  the  cervical  canal  becomes  continuous 
with  that  of  the  uterine  cavity  proper.     This  part  lies  at  the  level  of 
the  isthmus  uteri  (v.  fig.   16)  and  is  also  the  point  where  the  com- 
plicated uterine  musculature  passes  into  the  simpler  cervical  muscular 
arrangement.      The  folds  of  the  arbor  vitse  sometimes  cease  at  this 
point  but  may  pass  above  it  or  in  multiparse  may  end  below  it. 


FIG.  15. 

DIAGRAM  of  UTERUS  to  show  divisions  of  Cervix  (Schroeder). 

a  Vaginal  portion ;  6  Intermediate  portion ;  c  Supravaginal  portion ;  Bl  Bladder    P  Peritoneum. 
The  dotted  line  shows  peritoneum. 

Kiistner  also  alleges  that  for  i  cm.  (i  in.)  below  the  os  internum  as 
defined  by  him  the  cervical  substance  and  mucous  membrane  are  like 
that  of  the  uterine  body  and  that  this  special  part  of  the  cervical  canal 
participated  in  the  menstrual  and  pregnancy  changes ;  and  he  there- 
fore terms  this  the  "  inferior  uterine  segment,"  and  speaks  of  a  "cervical 
decidua."  The  os  internum  is  believed  by  some  to  be  at  the  level 
where  the  peritoneum  passes  on  to  the  bladder. 

While  the  two  great  divisions  of  the  uterus  are  the  body  and  cervix,  Lower 
it  is  of  importance  to  keep  in  mind  that  in  pregnancy  we  distinguish  a 
special  part  of  the  body  as  the  Lower  Uterine  Segment.  It  has  the 
following  characteristics  :  that  the  peritoneum  is  loosely  attached  over 
it,  the  muscular  wall  thinner  there  and  the  muscular  bundles  more 
separable ;  further,  it  plays  in  labour  a  passive  role,  and  comes  to  be 
marked  off  from  the  part  above  by  a  thickening  in  the  wall  known  as 


18 


ANATOMY  OF  PELVIS. 


Body 


Cervix 


the  contraction  or  retraction  ring.     We  may  show  the  relations  of  all 
the  divisions  in  the  following  scheme  : — 

(  Upper  Portion. 
(in  pregnancy)  j  Lower  Uterine  Segment. 

I  supra-vaginal  portion. 
.  -<  intermediate        ,, 
'  vaginal  ,, 

Kiistner,  as  we  have  seen,  speaks  of  the  inferior  uterine  segment  as 
cervical  in  origin. 

Structure       Structure  of  the  Uterus.— If  the  uterus  be  viewed  in  vertical  mesial 
of  Uterus.  secti011)  it  will  be  seen  to  be  made  up  of  three  distinct  elements,  viz., 
peritoneum,  unstriped  muscular  fibre,  and  mucous  membrane  (fig.  13,  B.}. 
The  peritoneum  covers,  partially,  its  external  surface ;  the  mucous  mem- 
brane lines  the  cavity  of  the  body  and  cervix ;  while  the  muscular  fibre, 
by  far  the  largest  constituent,  forms  the  tissue  lying  between  these. 
Peritoneum     The  Peritoneum  of  the  Uterus  clothes  its  posterior  surface  (except 
of  Uterus.  the  vaginal  and  middle  portions  of  the  cervix),  but  only  dips  down 


Ligaments 
of  Uterus. 


FIG.  16. 

CORONAL  SECTION  of  UTERUS  (Kustner). 
a.  a.  Uterine  opening  of  Fallopian  tubes ;  o.  i.  Os  internum  ;  o.  e.  Os  externum. 

on  the  front  surface  as  far  as  the  isthmus,  at  which  level  it  is  reflected 
on  to  the  bladder  (fig.  13,  JB,  a).  At  the  sides  of  the  uterus  the  peri- 
toneum on  the  anterior  and  posterior  surfaces  runs  out  to  the  wall  of 
the  pelvis,  thus  forming  the  important  structures  known  as  the  broad 
ligaments. 

The  Ligaments  of  the  uterus  are — 

Broad  ligaments ; 

Round  ligaments ; 

Utero-sacral  and  Utero-vesical. 


STRUCTURE  OF  UTERUS.  19 

The  broad  ligaments  are  described  under  the  peritoneum.     (See  p.  40.) 

The  round  ligaments  are  two  in  number.     According  to  Rainey,  each  Round 

Ligaments. 


FIG.  17. 
DIAGRAM  of  Course  of  GLANDS  of  Mucous  MEMBRANE  OF  UTERUS  (Engeltnann).    (*$) 

springs  by  three  fasciculi  of  tendinous  fibres — the  inner  from  the  tendons 
of  the  internal  oblique  and  transversalis,  the  middle  from  the  superior 


FIG.  18. 

VERTICAL  SECTION,  through  the  Mucous  MEMBRANE  of  the  HUMAN  UTERUS  (Turner). 

Columnar  Epithelium,  the  cilia  are  not  represented ;  gg  Utricular  Glands  ;  ct,  ct  Interglandular 

Connective  Tissue  ;  vv  Blood-vessels ;  mm  Muscularis  Mucosae.    (•*$-) 

column  of  the  external  abdominal  ring  near  its  upper  part,  and  the  outer 
fasciculus  from  just  above  Gimbernat's  ligament.     These  unite  into  a 


20 


ANATOMY  OF  PELVIS. 


rounded  cord  which  crosses  in  front  of  the  deep  epigastric  artery  and 
passes  between  the  layers  of  the  broad  ligament  backwards,  downwards, 
and  inwards  to  the  anterior  and  superior  part  of  the  uterus.     Striped 
and  unstriped  muscle,  blood-vessels,  etc.,  are  found  in  each. 
Utero-  The  utero-sacral  ligaments  are  peritoneal  folds,  two  in  number,  enclosing 

figments  connective  tissue  and  unstriped  muscular  fibre,  passing  from  the  lower, 
'  lateral  part  of  the  body  of  the  uterus  outwards  and  backwards  towards 
the  second  sacral  vertebra.  They  are  known  as  the  folds  of  Douglas, 
and  form  part  of  the  upper,  lateral  boundaries  of  the  pouch  of  Douglas. 
They  are  of  the  highest  importance  practically.  The  peritoneum,  as  it 
passes  between  uterus  and  bladder,  constitutes  the  utero-vesical  ligaments. 
Muscula-  The  Musculature  of  the  Unimpregnated  Uterus  is  of  little  importance 
in  Gynecology,  and  needs  only  a  passing  notice.  Three  coats  are 


FIG.  19. 

Mucous  MEMBRANE  of  CERVIX  in  Microscopical  Section  (de  Sinety). 

t  Ciliated  Columnar  Epithelium,  Cilia  not  shown  ;  g  Glands ;  in  Muscular  Fibre  ;  v  Blood-vessels  ; 
ct  Connective  Tissue  shown  only  at  one  part  of  figure.    (*f) 

described  : — a  thin  subperitoneal  coat  passing  into  the  round  ligaments, 
broad  ligaments,  utero-sacral  and  utero-vesical  ligaments ;  a  middle  coat ; 
and  an  inner  concentric  and  very  abundant  layer  which  surrounds  the 
Fallopian  tubes,  os  externum,  and  os  internum.  The  student  should 
not  forget  that  the  arrangement  of  the  muscular  fibres  is  of  the  highest 
importance  in  practical  obstetrics. 

Mucous  The  Mucous  Membrane  of  the  cavity  of  the  body  of  the  uterus  is  a 

ofeuterua?  tnin  reddish-gray  layer,  about  1  mm.  (^T  inch)  thick  in  the  unimpreg- 
nated  but  fully  developed  organ.  It  is  set  on  the  inner  aspect  of  the 
muscular  layer  of  the  uterus  without  the  intervention  of  any  sub-mucous 
layer,  is  made  up  of  ciliated  columnar  epithelium  on  a  basis  of  connective 
tissue,  and  has  numerous  glands — the  utricular  glands.  On  section  and 


STRUCTURE  OF   UTERUS.  21 

microscopic  examination,  the  glands,  lined  by  the  ciliated  epithelium, 
lying  on  a  thin  membrana  propria,  can  be  seen  coursing  down  obliquely 
from  the  free  surface  and  ending  at  the  muscular  fibre.  Fig.  17  shows 
them  perpendicular,  but  this  is  less  correct,  as  Turner's  drawing  indi- 
cates (fig.  18).  The  glands  usually  bifurcate  at  their  lower  ends,  and 
two  may  have  a  common  mouth.  The  innermost  layer  of  muscular 
fibre  sends  up  prolongations  between  them — muscularis  mucosae. 

The  connective  tissue  in  which  the  glands  are  embedded  consists  of 
delicate  round  and  spindle-shaped  cells,  the  former  being  more  abundant 
near  the  surface,  the  latter  deeper.  Fibrillated  bundles  of  connective 
tissue  lie  also  between  the  cells  and  pass  out  between  the  muscular  fibre 
of  the  uterine  wall  (fig.  18).  According  to  Leopold,  the  connective  tissue 
is  in  the  form  of  a  plexus  of  fine  bundles,  covered  with  endothelial  plates 
each  with  a  nucleus.  The  spaces  between  these  bundles  form  lymph 
sinuses. 

The  mucous  membrane  lining  the  cervix  is  different  in  arrangement  Mucous 
and  structure  from  that  lining  the  cavity  of  the  uterus.  It  is  thrown 
into  numerous  folds,  presenting  to  the  naked  eye  the  appearance  known 
as  the  arbor  vitse,  which  consists  of  a  longitudinal  mesial  ridge  on  the 
anterior  and  posterior  walls,  from  both  sides  of  which  secondary  ridges 
branch  off  obliquely.  It  is  lined  throughout  with  a  single  layer  of 
epithelium  (fig.  19),  which  is  ciliated  on  the  elevated  portion  of  the  ridges, 
but  is  columnar  in  the  depressed  portions  (de  Sinety}. 

The  upper  boundary  of  the  arbor  vitse  vai'ies.  The  boundary  lies  about 
midway  between  os  externum  and  fundus.  Before  puberty,  the  folds 
pass  up  into  the  cavity  of  the  body.  In  multiparse,  they  do  not  pass  up 
so  far  as  in  nulliparse  (Kiistner). 

The  glands  are  of  the  racemose  type,  and  consist  of  elongated  repeatedly- 
branching  ducts,  which  extend  deeply  into  the  connective  tissue,  and  are 
somewhat  dilated  at  their  extremities  (Ruge  and  Veit}.  They  are  lined 
by  columnar  epithelium,  resting  on  a  membrana  propria,  and  open  on  the 
ridges  and  furrows  of  the  mucous  membrane. 

There  is  a  sharp  line  of  demarcation  between  this  single  layer  of 
epithelium  (columnar  and  ciliated)  which  lines  the  cervical  canal  and  the 
epithelial  covering  of  the  external  surface  of  the  vaginal  portion,  and  this 
line  of  demarcation  corresponds  in  the  adult  to  the  os  externum.  Beyond 
the  os  externum,  the  epithelial  covering  has  all  the  characters  of  skin ;  it 
consists  of  vascular  papillae  covered  with  many  layers  of  squamous 
epithelium.  The  vascular  papillae  are  not  easily  recognised  without  the 
help  of  reagents  (Ruge  and  Veit}.  The  epithelial  cells  are  like  those 
found  in  the  skin,  and  dovetail  into  one  another  by  denticulate  edges 
(de  Sinety}. 

It  is  a  disputed  question  whether  glands  are  present  on  the  vaginal 
aspect  of  the  normal  cervix.  De  Sinety  says  he  has  never  met  with  them 


22  ANATOMY  OF  PELVIS. 

except  in  the  neighbourhood  of  the  os  externum,  and  their  occurrence 
there  he  attributes  to  an  eversion  of  the  mucous  membrane  of  the  canal. 
Ruge  and  Veit  also  consider  the  existence  of  glands  as  a  pathological 
condition,  which  is,  however,  easily  induced. 

The  normal  histology  of  the  cervix  uteri  has  an  important  bearing  on 
the  pathology  of  the  so-called  ulcerations  and  on  laceration  of  the  cervix 
and  ectropium. 

FALLOPIAN    TUBES. 

Fallopian        The  Fallopian  tubes  are  two  tubes,  one  on  each  side  of  the  uterus, 
Tubes.        running  sinuously  from  its  upper  angles  out  towards  the  side  of  the 


Isthmus. 


FIG.  20. 

VIEW  from  behind  of  the  LATERAL  ANGLE  of  the  UTERUS,  with  part  of  the  Left  Broad  Ligament, 
Fallopian  Tube,  Ovary,  and  Parovarium  (Henle). 

a  Uterus ;  6  Isthmus  of  Fallopian  Tube  ;  c  Ampulla ;  y  has  Parovarium  to  the  right,  and  Fimbriated 
end  of  Fallopian  Tube  and  Ovarian  Firnbria  just  below  it ;  d  Parovarium  ;  e  Ovary  ;  /Ovarian 
Ligament ;  I  Infundibulo-pelvic  Ligament  (}).  The  topographical  relations  are  disturbed  here. 

pelvis  (figs.  20  and  50).  They  lie  enclosed  in  the  upper  free  margin  of 
the  broad  ligaments,  and  vary  in  length  from  10  to  16  cm.  (4  to  6  inches). 
They  are  not  of  equal  length,  the  right  being  frequently  longer  than  the 
left. 

The  Fallopian  tube,  the  uterus  lying  to  the  front  (anteverted),  has 
been  found  by  His  to  pass  first  outwards  and  then  upwards  over  the 
ovary  the  fimbriated  end  lying  on  the  posterior  aspect  of  the  ovary 
(PI.  I.  fig.  2).  Three  parts  come  up  for  consideration — the  isthmus, 
the  ampulla,  and  the  pavilion  or  fimbriated  end. 

The  isthmus  is  the  straight  narrow  part  of  the  tube  (fig.  20,  6),  which 
at  its  internal  end  opens  into  the  uterine  cavity,  and  has  a  lumen  barely 


OVARIES.  23 

admitting  a  bristle.     On  transverse  section  the  diameter  of  the  whole 
thickness  is  about  2  to  3  mm. 

The  ampulla  is  the  curved  and  thick  part  of  the  tube  (fig.  20,  c),  Ampulla, 
having  an  average  diameter  of  about  6-8  mm.,  with  a  lumen  admitting 
the  ordinary  uterine  sound. 

The  free  fimbriated  end  of  the  Fallopian  tube  is  expanded  and  funnel-  Fimbrise. 
shaped  (infundibulum) ;  and  it  is  provided  with  primary  and  secondary 
fimbriae  surrounding  the  opening  of  the  tube  to  which  they  converge. 
One  special  fimbria  runs  to  the  ovary  (fig.  20,  g). 

On  section  the  Fallopian  tube  is  seen  to  be  made  up  of  three  layers  Structure 
from  without  inwards:  viz.,  peritoneum,  longitudinal  and  circular  unstriped  Jjj,ubg  opiau 
muscular  fibres  (the  latter  being  inner),  and  mucous  membrane  lined 
with  ciliated  columnar  epithelium.     Connective  tissue  and  elastic  fibres 
lie  between  the  peritoneal  and  muscular  layers.     No  glands  exist  in 
the  mucous  membrane  which  is  much  folded  in  a  longitudinal  direction, 
especially  in  the  ampulla. 

It  is  remarkable  that  the  ciliated  epithelium  lining  the  Fallopian  tube 
and  pavilion  should  be  continuous  with  the  squamous  epithelium  of  the 
peritoneum ;  and  that,  further,  there  is  direct  continuity  between  the 
vagina,  uterus,  Fallopian  tubes,  and  peritoneum, — so  that  the  peritoneal 
sac  in  the  female  is  not  closed  as  in  the  male. 

Parovarium  or  Organ  of  Rosenmiiller. — If  the  broad  ligament  be  heldPar- 
between  the  light  and  the  observer's  eye,  this  rudimentary  structure ov 
will  be  seen  enclosed  in  its  folds  in  the  space  between  the  ovary  and 
ampulla  (fig.   20,  d).     It  consists  of  closed  tubules  lined  with  ciliated 
epithelium,  which  converge  towards  the  ovary,  and  are  united  by  a 
longitudinal  one. 

In  the  cow  and  sow  the  longitudinal  tube  persists,  extending  in  the  latter  animal  from 
a  point  a  little  above  the  division  of  the  uterus  into  its  cornua  down  the  side  wall  of 
the  vagina  and  opening  into  the  vagina  at  the  sides  of  the  urethral  orifice.  These  are 
named  Gartner's  canals  after  their  chief  investigator,  and  they  correspond  to  the  vas 
deferens,  etc.,  in  the  male.  Beigel  has  shown  that  these  canals  may  be  found  in  the 
uterus  of  the  human  foetus,  a  statement  verified  by  Kolliker,  Dohrn,  and  others. 
According  to  Rieder,  they  may  persist  either  as  a  closed  muscular  epithelium-lined  tube 
or  as  a  muscular  bundle  without  epithelium.  The  epithelial  lining  consists  of  a  single 
or  double  layer  of  cylindrical  cells  (cells^G^u. ) :  this  is  surrounded  by  connective 
tissue  and  by  three  coats  of  unstriped  muscular  fibre  (inner  and  outer  longitudinal 
and  middle  circular).  It  may  produce  one  form  of  cervical  or  vaginal  cyst  as  was 
shown  by  Von  Preuschen  (v.  chapters  on  Ovarian  Pathology  and  Vaginal  Cysts). 


OVARIES. 

The  ovaries,  two  in  number,  lie  one  on  each  side  of  the  uterus,  pro- 
jecting markedly  through  the  posterior  layer  of  the  broad  ligament. 

Form,  Size,  and  Relations. — The  ovary  is  a  small  oval-shaped  body  Ovaries. 


24 


ANATOMY  OF  PELVIS. 


about  the  size  of  an  almond,  the  weight  of  which  varies  from  60  to  135 
grains.     According  to  Farre  its  measurements  are  as  follow : — 


Greatest 
Smallest 
Average 


Longitudinal 
Diameter. 

2  in. 
1  in. 
Ik  in. 


FIG.  21. 

SECTION  OF  CAT'S  OVARY  (Schrijri).  The  free  border  of  the  ovary  is,  in  the  fig.,  above;  the  base 
of  attachment — li  Hum — below.  The  division  into  Cortical  and  Medullary  Layers  is  indicated. 
Note  smallest  Giaafian  Follicles  at  surface,  and  larger  ones  not  so  superficial.  A  Corpus 
Luteum  lies  to  the  left  of  the  hilutn.  (f). 


FIG.  22. 
SECTION  through  the  CORTICAL  part  of  the  OVARY  (Turner) 


The  ovary  has  an  anterior  and  posterior  border,  and  an  upper  and 
lower  surface.     The  posterior  border  is  convex  and  free,  the  anterior 


OVARIES.  25 

flattened  and  attached  to  the  broad  ligament.  It  should  be  noted  that 
this  anterior  border  is  called  the  hilum,  and  that  the  blood-vessels  and 
nerves  enter  there. 

The  position  of  the  ovary  will  be  discussed  afterwards  (p.  57),  but  at 
present  it  is  sufficient  to  consider  it  as  lying  behind  the  broad  ligament 
suspended  as  it  were  by  the  infundibulo-pelvic  ligament  so  that  its 
long  axis  lies  more  or  less  parallel  to  the  axis  of  the  brim  of  the 
pelvis. 

Ligaments  of  the  Ovary. — In  addition  to  the  attachment  which  the  Ligaments 
broad  ligament  gives  to  the  ovary,  two  important  ligaments  are  described0 
— the  ovarian  ligament  and  the  infundibulo-pelvic  ligament. 

The  Ovarian  Ligament  (fig.  20, /)  is  about  3  cm.  (li  inch)  long,  and  Ovarian 
extends  from  the  inner  end  of  the  ovary  to  the  corresponding  upper  lgam 
angle  of  the  uterus,  just  below  the  uterine  origin  of  the  Fallopian  tube. 
It  is  a  longitudinal  fold  of  the  peritoneum  into  which  the  unstriped 
muscular  fibre  of  the  uterus  is  prolonged. 

The  Infundibulo-Pelvic  Ligament  (fig.  20,  I)  is  about  2  cm.  long,  andlnfun- 
runs  from  the  outer  end  of  the  Fallopian  tube  to  the  side  wall  of  thepe^" 
pelvis.     It  is  simply  that  part  of  the  upper  margin  of  the  broad  ligament  Ligament, 
unoccupied  by  Fallopian  tube. 

The  Ovarian  Fimbria  (fig.  20,  g)  prevents  the  separation  of  the  ovary  Ovarian 
and  infundibulum  tubse.  Fimbria, 

Thus  the  ovary  is  kept  in  position  by  its  attachment  to  the  broad  liga- 
ment, by  the  ovarian  and  by  the  infundibulo-pelvic  ligaments.  Its  own 
specific  gravity  has  also  a  share,  i.e.,  the  ovary  floats  at  a  certain  level. 

Structure  of  the  Ovary. — The  ovary  is  covered  with  epithelium  differing  Structure 
from  the  squamous  epithelium  of  the  peritoneum  in  being  made  up  of     Ovarv' 
columnar  nucleated  cells  with  a  dull  lustre.     It  is  continuous,  however, 
with  the  peritoneal  epithelium,  the  line  of  contact  being  marked  by  a 
whitish  and  elevated  line.     The  epithelium  covering  the  ovary  is  known 
as  the  germ-epithelium.     This  distinctive  term  is  of  importance  in  con- 
nection with  the  development  of  the  ova,  and  will  be  more  particularly 
alluded   to   afterwards.     A   tunica  albuginea   made   up   of  condensed 
connective    tissue    has    been    described    as    lying    below   the    germ- 
epithelium. 

On  section  and  microscopical  examination,  the  ovary  is  found  to 
consist  of  connective  tissue  with  the  structures  known  as  the  Graafian 
follicles  embedded  in  it,  along  with  blood-vessels,  nerves,  lymphatics, 
and  some  unstriped  muscular  fibre.  These  are  enclosed  in  the  epithelial 
covering  already  described.  The  connective  tissue  is  divided  into  a 
cortical  and  medullary  layer  ;  the  former  lying  beneath  the  peritoneum, 
the  latter  being  at  and  near  the  hilum  (fig.  21).  The  medullary  layer 
is  very  vascular,  and  has  some  unstriped  muscular  fibre  round  the 
branches  of  the  ovarian  artery  (fig.  22). 


26 


ANATOMY  OF  PELVIS. 


The  Graafian  follicles  are  scattered  through  the  whole  substance  of 
the  ovary.     The  following  points  should  be  carefully  noted : — 

a.  The  younger  and  smaller  Graafian  follicles  lie  in  the  cortical  layer. 
Their  diameter  is  generally  about  y^  in.,  and  they  exist  in  immense 
numbers.     According  to  careful  estimates,  the  ovary  of  a  female  infant 
may  contain  40,000  to  70,000  such  follicles. 

b.  The  larger  follicles  are  much  fewer  in  number  and  lie  deeper  in 
the  ovary.     Diameter  ^-th  to  TJ^th  in. 

c.  There  are  also  still  larger  follicles  nearer  the  surface  than  the 
latter.     These  have  advanced  from  the  deeper  layer  (vide  under  Men- 
struation). 


FIG.  23. 

A  SECTION  OF  WHOLE  VAGINA  passing  through  Lateral  Fornix  ;  and  B  SECTION  OF  UPPER  THIRD 
passing  through  the  Cervix  Uteri  (Hart). 


P.  D.  Pouch  of  Douglas ;  ut  Uterus ;  o  e  Os  Externum ;  Vg  Vagina  ;  p  f  P< 
a  f  Anterior  Fornix  ;  V.u.p.  Vesico-uterine  Peritoneum  ;  Bl.  Bl 


'osterior  Fornix ; 
Bladder. 


Structure  of  a  Graafian  Follicle.     This  consists  of 

1.  A  Tunica  fibrosa  and  Membrana  propria ; 

2.  The  Membrana  granulosa,  a  layer  of  nucleated  columnar  epithelial 
cells  forming  the  discus  proligerus  at  one  part ; 

3.  Fluid — the  liquor  folliculi. 


VAGINA. 


27 


The  ovum  (diameter  y^y  to  j-^  in.)  lies  in  the  discus  proligerus  ;  it 
has  the  following  structure  :  — 

1.  External  envelope  —  zona  pellucida,  a  homogeneous  membrane, 

2.  Yelk  protoplasm, 

3.  Germinal  vesicle  (T^th  in.  diameter), 

4.  Germinal  spot  (^-(nnrth  m-  diameter). 


THE   VAGINA. 


The  vagina  is  a  mucous  slit  in  the  pelvic  floor,  extending  from  the  Vagina- 

Position. 


FIG.  24. 

ANTERIOR  VAGINAL  WALL  AND  MULTIPAROUS  CERVIX,  looked  at  from  behind  (Henle). 
a  TJrethral  Orifice  ;  6  Anterior  Vaginal  Cohimn  ;  c  Cervix  Uteri.  (|) 


hymen  to  the  cervix  uteri,  and  lying  between  the  urethra  and  bladder  in 
front  and  the  rectum  behind.  In  the  upright  posture  it  makes  an  angle  of 
about  60°  with  the  horizon,  i.e.,  it  is  nearly  parallel  to  the  pelvic  brim. 

The  vagina  has  two  walls,  an  anterior  and  posterior,  which  are  con- Vaginal 
tinuous  at  their  sides.     The  anterior  vaginal  wall  is  triangular  in  shape, WaUs- 
the  base  being  above.     Its  lower  limit  is  marked  out  by  the  hymen. 


28 


ANATOMY  OF  PELVIS. 


At  its  upper  end  it  is  reflected  down  to  a  small  extent  on  the  an- 
terior lip  of  the  cervix  uteri,  the  anterior  fornix  being  thus  formed 
(fig.  23).  It  is  closely  incorporated  with  the  urethra,  but  between  it 
and  the  posterior  aspect  of  the  bladder  there  is  loose  connective  tissue. 
Its  length  is  about  5  cm.,  i.e.,  2-2^  inches. 

Vaginal          The  mucous  membrane  of  the  wall  is  arranged  in  folds  roughly  trans- 

Murnbrane  verse-     At  its  lower  end  is  a  vertical  mesial  single  or  double  thickening 

of  the  mucous  membrane,  about  2  cm.  long,  known  as  the  anterior  vaginal 

column  (fig.  24,  b).     This  begins  near  the  urethral  orifice,  or  about  1|  cm. 

above  it.     According  to  Budin,  the  columns  are  prolonged  on  the  hymen. 

The  posterior  vaginal  wall  is  triangular  in  shape,  and  extends  from 

the  vaginal  orifice  upwards  to  the  cervix  uteri,  upon  which  it  is  reflected, 


FIG.  25. 

DIAGRAM  OK  VERBAL  MESIAL  SECTION  OF  FEMALE  PELVIS,  showing  Sigmoid  curve  of  posterior 
Vaginal  Wall  (Schultze).  (J) 

thus  forming  the  posterior  fornix  vaginee,  which  is  deeper  than  the 
anterior  one.  Its  length  is  about  7|  cm.  (3  inches)  i.e.,  about  2i  cm. 
(nearly  an  inch)  longer  than  the  anterior.  It  is  also  transversely  rugous, 
and  has  a  posterior  column  analogous  to  the  anterior,  but  smaller. 

While  the  direction  of  the  anterior  vaginal  wall  is  almost  straight, 
that  of  the  posterior  vaginal  wall  is  sigmoid  (fig.  25).  The  curve  varies, 
however,  according  to  the  position  of  the  uterus  and  the  fulness  or 
emptiness  of  the  adjacent  bladder  and  rectum. 


VAGINA. 


29 


When  the  bladder  and  rectum  are  empty,  we  find  the  direction  of  the 
vagina  parallel  to  the  pelvic  brim.  When  the  bladder  is  distended,  the 
vagina  is,  chiefly  at  its  upper  part,  driven  nearer  the  sacrum ;  while,  if 
the  rectum  be  distended,  the  vaginal  axis  may  be  almost  perpendicular. 

Stwicture  of  Vagina. — The  vaginal  wall,  on  section  and  microscopical  Structure 
examination,  is  found  to  consist  of  nrncous  membrane,  made  up  of  epi-° 
thelium  (the  superficial  layer  being  squamous  and  nucleated,  the  deeper 
layer  cylindrical  and  with  elongated  nuclei),  connective  tissue,  elastic 


FIG.  26. 

HORIZONTAL  SECTION  OF  THE  PELVIC:  FLOOR  AT 
THE  PELVIC  OUTLET  (Henle). 

Da  Urethra ;  Va  Vagina ;  R  Anus  ; 
L  Levator  Ani. 


FIG.  27. 

HORIZONTAL  SECTION  OP  THE  POSTERIOR  WALL 
OF  BLADDER  AND  THE  ANTERIOR  WALL  OF 
THE  VAGINA  (Henle.) 

«  Epithelium  of  the  Bladder ;  6  Mucosa ;  c  Layer 
of  circular  fibre  ;  d  Layer  of  longitudinal 
fibres  ;  e  Loose  Tissue  ;  /  Layer  of  circular 
fibres  ;  g  Layer  of  longitudinal  fibres ;  h 
Mucosa ;  i  Epithelium  of  Vagina.  (>f-) 


tissue,  and  some  unstriped  muscular  fibre.  The  superficial  layer  of 
the  connective  tissue  forms  papillae,  into  which  blood-vessels  project. 
The  epithelium  is  therefore  ridged.  External  to  this  lie  two  layers  of 


30  ANATOMY  OF  PELVIS. 

unstriped  muscular  fibre;  the  inner  longitudinal,  the  outer  circular 
(Henle).  Breisky  alleges  the  inner  to  be  circular.  Von  Preuschen  has 
described  glands  in  the  vagina  but  they  are  very  few  in  number.  He 
found  the  ducts  lined  with  squamous  epithelium  and  the  deeper  part 
with  ciliated  epithelium— the  latter  being  continuous  with  the  cylindri- 
cal deep  cells  of  the  vagina.  Gland-like  crypts  and  lymph  follicles  also 
exist  (Lowenstein)  (fig.  27).  The  whole  is  surrounded  by  loose  connec- 
tive tissue,  containing  the  outer  venous  plexus  of  the  vagina  (fig.  27). 

As  already  said,  the  vagina  is  a  mere  slit  in  the  pelvic  floor,  although 
it  is  often  erroneously  described  as  a  tube  or  cavity.  On  vertical 
section,  as  fig.  23  shows,  it  appears  as  a  mere  linear  slit;  while  on  trans- 
verse section  it  is  H-shaped,  or  crescentic  (figs.  26  and  44).  The  vagina  is 
eminently  dilatable  and  its  walls  separable,  as  will  be  more  fully  consi- 
dered under  the  structural  anatomy  of  the  pelvic  floor  ;  but  this  dilata- 
tion or  separation  is  the  result  of  posture  with  manipulation,  or  of  partu- 
rition. Under  mere  changes  of  posture  the  vagina  retains  its  slit-like  form. 

THE    BLADDER. 

Position. — The  empty  female  bladder  lies  behind  the  pubes  and  in 
front  of  the  vagina.  We  here  consider  the  urethra  and  bladder. 

Urethra—  The  urethra  is  a  straight  slit  (some  describe  it  as  sigmoid)  about  If 
inches  long,  with  thick  walls  closely  incorporated  with  the  anterior 
vaginal  wall  behind.  It  runs  parallel  to  the  plane  of  the  pelvic  brim. 
Its  lower  opening  is  known  as  the  meatus  urinarius,  the  position  of 
which  has  been  already  considered  in  the  section  on  the  External  Geni- 
tals ;  its  upper  opening  is  at  the  neck  of  the  bladder.  On  section  and 
microscopical  examination,  its  mucous  membrane  is  found  covered  with 
squamous  epithelium  in  its  lower  part ;  while  higher  up  it  is  like  that 

Micro-        of  the  bladder,  and  is  very  rich  in  elastic  fibres.     There  is  a  double 

Structure,  layer  of  unstriped  muscular  fibre,  the  longitudinal  layer  being  internal 
and  the  circular  outside  ;  and,  according  to  Uffelman,  a  circular  (inner) 
and  longitudinal  layer  of  striped  muscle,  which  stretches  from  the  neck  of 
the  bladder  to  within  6  in.  (1^  cm.)  of  the  meatus  urinarius.  Luschka 
also  describes  a  special  sphincter  of  the  vaginal  and  urethral  orifices. 
It  should  be  further  noted  that  the  mucous  membrane  is  folded  longi- 
tudinally, and  contains  mucous  glands  lined  with  cylindrical  epithelium, 
papillae,  and  lacunae,  and  also  villous  tufts  near  the  meatus ;  and  that 
there  is  a  submucous  layer  between  the  mucous  membrane  and  un- 

Skene's  striped  muscle,  containing  many  veins.  Recently  Skene  of  New  York 
has  described  two  tubules  in  the  female  urethra.  They  lie  on  each 
side  (figs.  28  and  29),  "  near  the  floor  of  the  female  urethra,  and  extend 
up  from  the  meatus  urinarius  for  about  £  inch  They  lie  beneath 
the  mucous  membrane,  and  in  the  muscular  walls  of  the  urethra."  We 
have  in  section  of  the  female  urethra : — 


BLADDER, 

Mucous  membrane ; 

Submucous  layer ; 

Muscular  layer,  longitudinal  and  circular,  unstriped  ; 

do.  do.         striped  (Uffelman). 


31 


FIG.  28. 

TRANSVERSE  SECTION  of  URETHRA  much  enlarged  (Skene). 
a  Urethral  Canal ;  b  b  Glands  described  by  Skene ;  c  Vein  ;  d  Artery. 


FIG.  29. 

URETHRA  LAID  OPEN  from  above,  showing  glands  with  probes  passed  in  (Skene). 


Bladder- 
Openings. 


Structure 
of  Bladder. 


3i>  ANATOMY  OF  PELVIS. 

External  to  these,  there  is  the  anterior  vaginal  wall  behind  and  loose 
tissue  in  front. 

According  to  Henle,  the  closed  urethral  slit  is  on  section  transverse 
near  the  bladder,  sagittal  at  the  rneatus,  and  star-shaped  between  these 
two  points. 

In  the  bladder  proper  we  have  three  openings — the  internal  orifice  of 
the  urethra  and  the  orifices  of  the  two  ureters.  The  latter  lie  one  on 
each  side,  about  1£  inches  from  the  internal  orifice.  These  openings 
give  us  the  landmarks  for  the  division  of  the  bladder  into  neck,  base, 
and  body.  All  above  the  lines  joining  the  ureteric  openings  and  the 
centre  of  the  symphysis  is  the  body;  all  below  is  the  base,  and  that 
portion  between  the  ureteric  openings  and  the  internal  orifice  is  the 
trigone.  Just  above  the  ureters  is  the  bas  fond. 

The  wall  of  the  bladder  is  made  up  of  three  layers,  viz.,  a  mucous, 
a  muscular,  and  a  peritoneal. 

The  mucous  membrane  consists  of  connective  tissue  lined  by  several 
layers  of  transitional  or  multiform  epithelium  (fig.  30).  It  is  arranged 


Ureters. 


FIG.  30 

EPITHELIAL  CELLS  from  the  Mucous  MEMBRANE  of  the  BLADDER.  Those  in  the  upper  row  are  the 
superficial  squamous  cells  ;  those  in  the  lower  row  are  the  peculiar  cells  of  the  middle  stratum 
(Turner). 

in  folds,  except  over  the  trigone  and  openings.     The  folds  or  rugse  are 
due  to  the  laxity  of  the  submucous  coat. 

The  muscular  coat  of  the  bladder  is  of  the  unstriped  variety,  and  has 
a  complicated  arrangement.  There  are  external  longitudinal  fibres, 
circular  fibres  within  these,  and  an  internal  longitudinal  layer  on  which 
rests  the  submucous  coat.  It  is  disputed  whether  there  is  a  sphincter 
at  the  neck  of  the  bladder.  Probably  there  is  not ;  but  the  puckering 
of  the  mucous  membrane  at  the  neck  is  alleged  to  have  a  valve-like 
function. 

The  peritoneal  covering  of  the  bladder  will  be  considered  subse- 
quently. 

The  relations  of  the  ureters  are  of  importance  with  regard  to 
inflammatory  exudations,  fistula),  and  excision  of  the  uterus  for 
cancer. 


SHAPE  AND   POSITION  OF  BLADDER. 


33 


To  Freund  and  Joseph,   Luschka,  Garrigues,   Holl,  and  Polk,  we  are 
indebted  for  anatomical  researches  as  to  the  course  of  the  ureter  in  the 


FIG.  31. 
RELATION  OF  URETER  ON  THE  EIGHT  SIDE  OF  A  DISSECTED  PELVIS  (Holl). 

V  Vagina  ;  C  Cervix  ;  B  Bladder ;  Ur,  Ur,  Ureter. 

1  Common  iliac  artery ;  2  External  iliac  artery  ;  3  Internal  iliac  artery  ; 

4  Uterine  artery  ;  5  Pudic  artery  ;  6  External  iliac  vein. 

pelvis.     We  give  Holl's  drawing  of  the  right  ureter  (fig.  31),  and  follow 
in  the  main  his  description, 

Its  course  may  be  conveniently  described  in  four  portions. 

(1. )  From  the  brim  of  the  pelvis  to  the  origin  of  the  uterine  from  the  internal  iliac  artery. 
About  *6  inches  (1J  cm.)  below  the  division  of  the  common  iliac  artery  into  its  external  and 
internal  branches,  the  Ureter  passes  over  the  external  iliac  vessels,  and  lies  in  front  of  the 
internal  iliac  artery  and  then  in  the  space  between  the  internal  iliac  artery  and  external 
iliac  vein.  So  far,  the  portion  described  is  at  or  about  the  level  of  the  pelvic  brim. 

The  Ureter  next  passes  down  into  the  true  pelvis,  and  at  the  origin  of  the  obturator, 
vesical,  and  uterine  arteries  begins  to  describe  a  bow-shaped  portion  3?  inches  (9  cm.) 
long,  with  the  greatest  convexity  of  the  bow  where  the  uterine  artery  crosses  it.  By 
this  crossing,  the  bow-shaped  portion  of  the  Ureter  is  divided  into  an  upper  and  a  lower 
part. 

(2.)  From  the  origin  of  the  uterine  artery  to  where  the  Ureter  is  crossed  by  it.  This  is 
the  upper  part  of  what  is  known  as  the  bow-  or  spindle-shaped  portion. 

(3.)  From  v:here  the  Ureter  is  crossed  by  the  uterine  artery  to  the  bladdei — the  lower 
part  of  the  spindle-shaped  portion. 
C 


34 


ANATOMY   OF  PELVIS. 


Shape  and 
Position  of 
Bladder. 


The  uterine  artery  as  it  crosses  the  Ureter  is  separated  from  it  by  a  venous  plexus. 
In  this  way,  a  distance  of  about  if  inch  (1  cm.)  separates  Ureter  and  uterine  artery  at 
this  point. 

At  the  level  of  the  os  uteri  externum  the  uterine  artery  crosses  the  Ureter  to 
reach  the  uterus,  and  at  this  point  the  Ureter  is  I  inch  (1J  cm.)  distant  from  the 
cervix.  The  course  of  this  portion  is  of  great  importance.  It  is  1'6  inch  (4  cm.)  long, 
lies  in  relation  to  the  side  of  the  vagina,  and  then  for  the  last  two  centimetres,  before 
it  pierces  the  bladder,  lies  between  the  anterior  vaginal  wall  and  the  posterior  wall 
of  the  bladder.  The  Ureter  does  not  pass  lower,  therefore,  than  about  the  middle  of 
the  anterior  vaginal  wall. 

(4.)  The  portion  piercing  the  bladder.  The  Ureter  runs  through  the  bladder  wall 
obliquely  downwards  and  inwards  for  from  '6  to  "8  inches  (1'5  to  2  cm.). 

Shape   of  empty  Bladder   and  changes  in   its  position. — The    empty 


FIG.  32. 

VERTICAL  MESIAL  SECTION  of  FEMALE  PELVIS,  showing  Y-shape  of  Bladder  (Fa, -*t). 
a  uterus,  b  bladder,  c  rectum.  (!) 


SHAPE  AND   POSITION  OF  BLADDER.  35 

female  bladder  lies  completely  behind  the  pubes,  and  has  its  fundus 
covered  by  peritoneum.  When  empty  and  viewed  in  mesial  section  it 
may  present  one  of  two  shapes.  In  the  large  majority  of  specimens 
figured,  it  forms  with  the  urethra  a  Y-shape  on  sagittal  mesial  section. 
The  oblique  legs  of  the  Y  may  be  about  equal  in  size,  or  the  posterior 
may  be  shorter  (figs.  32,  38).  This  form  is  so  common  that  it  has 
been  accepted  hitherto  by  all  authors  as  the  normal  one.  In  certain 
cases,  however,  but  not  in  so  many  as  the  former,  the  empty  bladder 
cavity  forms  with  the  urethra  a  continuous  tube  on  vertical  mesial 
section  (fig.  33).  In  such  cases,  it  is  oval  in  shape,  corrugated,  and 
firm  to  the  touch.  This  latter  shape  is  the  one  always  found  in  the 
lower  animals,  such  as  the  rabbit  and  dog,  and  is  the  only  one  seen 
in  the  human  foetus.  If,  therefore,  the  pelvic  floor  be  viewed  on  its 


FIG.  33. 

VERTICAL  MESIAL  SECTION  OF  FEMALE  PELVIC  FLOOR,  showing  contracted  bladder  in  a  suicide 
(Untune).  The  peritoneum  descends  in  front  of  the  uterus  to  &  and  behind  it  to  d ;  b  a  and 
d  c  are  loose  extra-peritoneal  tissue.  (|) 

peritoneal  aspect,  the  fundus  of  the  empty  bladder  will  be  found  to 
be  very  often  large  and  concave,  while  in  some  cases  it  is  small  and 
convex.  In  the  former  case,  the  inner  surface  of  the  upper  segment 
of  the  bladder,  large  in  area,  is  in  contact  with  the  surface  of  the  lower 
segment ;  in  the  latter,  the  anterior  and  posterior  walls,  small  in  area 
touch  one  another. 

It  is  probable  that  when  the  bladder  has  the  Y-shape  on  section,  it  is 
relaxed  and  empty  (fig.  32) ;  and  when  the  oval  shape  (fig.  33),  it  has 
been  caught  in  systole.  The  bladder  contracts  to  expel  the  urine  and 
then  relaxes.  Between  the  acts  of  urination  the  bladder  is  therefore 
only  a  flaccid  sac.  Some  additional  facts  as  to  the  position  and  disten- 


36  ANATOMY  OF  PELVIS. 

tion  of  the  bladder  are  best  considered  further  on,  under  the  structural 
anatomy  of  the  pelvic  floor.  We  may  here  state,  however,  that  (1)  when 
empty,  in  the  non-parturient  female,  it  is  behind  the  pubes  (fig.  40);  (2) 
it  is  drawn  above  the  pubes  in  the  parturient  female ;  (3)  it  is  tilted 
above  the  pubes  in  retroversion  of  the  gravid  uterus. 


RECTUM. 


The  Rectum  is  not  separated  by  any  division  from  the  sigmoid  flexure, 
but  may  be  denned  as  extending  from  the  left  sacro-iliac  synchondrosis 


FIG.  34  a. 

RECTUM  INFLATED  (Chadinck). 
a  6  Sphincter  tertius ;  c  Ampulla  of  Rectum. 


FIG.  34  b. 

CORONAL  SECTION  THROUGH  ANUS  (Symington). 

r  rectum  ;  i » internal  sphincter ;  e  s  external 

sphincter  ;  I  a  levator  ani ;  v  vagina. 


to  the  anus.  It  curves  downwards,  backwards,  and  inwards,  to  about 
the  third  sacral  vertebra.  This  is  known  as  the  first  part  of  the  rectum ; 
it  is  completely  covered  by  peritoneum,  which  forms  the  mesorectum. 
The  peritoneum  is  reflected  from  the  rectum  on  to  the  upper  part  of  the 
vaginal  wall,  about  3  inches  above  the  vaginal  orifice.  Thereafter,  the 
rectum  lies  in  relation  anteriorly  to  the  posterior  vaginal  wall  to  which 
it  is  loosely  attached  until  about  1£  inches  from  the  anus. 

The  rectum  is  made  up  of  peritoneal  investment ;  unstriped  muscular 
fibre  in  two  layers,  longitudinal  and  circular,  the  former  being  the  outer ; 
a  submucous  coat ;  and  a  mucous  lining  with  its  muscularis  mucosae, 


RECTUM. 


37 


columnar  epithelium,  no  villi,  but  with  Lieberkuhnian  follicles  closely 
set  together.     At  the  upper  limit  of  the  anus,  the  circular  fibres  are  very  Micro- 
well  marked,  and  constitute  the  sphincter  ani  internus  (fig.  35).  Stmcture 
Certain  oblique  folds  in  the  rectum — consisting  of  mucous,  submucous,     Recturn- 


FIG.  35. 

PERPENDICULAR  SECTION  through  the  end  of  the  RECTAL  WALL  enlarged  (Ruedinger). 

1  Mucous  Membrane  of  the  Rectum  ;  2  boundary  between  Mucous  Membrane  and  skin  of  buttock  ; 
3  Fat ;  4  Levator  Ani ;  5  Sphincter  Ani  externus ;  9  Fibres  of  Longitudinal  Layer  separating 
external  Sphincter  into  parts ;  7  Sphincter  Ani  internus ;  8  Longitudinal  Fibres  of  muscular 
coat,  which  radiate  outwards  at  9  ;  13  Longitudinal  Fibres  of  Muscularis  mucosae  which  radi- 
ate outwards  at  12  ;  11  Circular  Fibres  of  muscular  coat ;  6,  10,  and  14  Slips  of  muscular  fibre 
passing  into  tissue  beyond. 

and  circular  unstriped  muscular  coats — are  of  special  interest.  One 
exists  li  inches  from  the  anus,  another  is  near  the  sacral  promontory, 
and  one  is  intermediate  (Turner).  The  lowest  (the  valve  of  Houston  or 
sphincter  ani  tertius  of  Hyrtl)  has  been  described  by  Chadwick  of 


38  ANATOMY  OF  PELVIS. 

lioston,  as  being  not  an  entire  circular  fold,  but  made  up  of  two  semi- 
circular constrictions,  one  on  the  anterior  wall,  and  one  on  the  posterior 
an  inch  higher  up  (fig.  34  «). 

Anus.  The  Anus  is  that  part  of  the  rectum  at  its  external  orifice.     It  is  about 

an  inch  long,  and  has  its  long  axis  directed  backwards  and  cutting  the 
axis  of  the  vagina  at  about  a  right  angle.  The  rectum,  therefore,  when 
in  contact  with  the  posterior  vaginal  wall  closely  follows  its  direction, 
but  at  a  little  above  the  anus  turns  sharply  backwards.  There  is  thus 
left  between  it  and  the  last  l^  inch  of  the  posterior  vaginal  wall,  an 
angular  interspace  to  be  filled  up  by  the  structure  known  as  the  peri- 
neal  body. 

During  life,  the  anus  is  closed  by  its  sphincters  in  such  a  way  that 
the  lateral  walls  are  in  contact  (Symington).  This  explains  that  the 
apparent  gaping  of  the  anus  in  sagittal  mesial  sections  is  approximately 
right  (v.  Plate  I.),  and  that  the  appearance  figured  at  page  67  is  wrong. 

Fig.  35,  from  Ruedinger,  shows  the  arrangement  of  voluntary  and 
involuntary  muscle  in  the  anus.  The  division  of  the  external  sphincter 
into  two  parts,  and  the  separation  of  the  lower  division  (5)  into  compart- 
ments by  fibres  from  the  longitudinal  unstriped  layer  (9),  are  noteworthy. 
Similarly  the  internal  sphincter  (7)  is  divided  into  compartments  by 
fibres  from  the  muscularis  mucosae  (13).  Near  the  anal  orifice  the 
mucous  membrane  has  certain  perpendicular  folds  in  it  known  as  the 
Columnae  Morgagni,  with  depressions  between  these — the  Sinus 
Morgagni  (fig.  2,  a). 

PERINEAL    BODY. 

Perineal  The  posterior  vaginal  wall  is  in  contact  with  the  anterior  rectal  wall, 
for  about  li  inches  above  the  apex  of  the  perineal  body,  there  being 
only  loose  tissue  between.  The  anus  has  its  long  axis  directed  back- 
wards, while  the  vaginal  axis  runs  forwards ;  we  thus  get  a  pyramidal 
space  filled  up  by  the  structure  known  as  the  Perineal  body  (Henle  and 
Savage). 

The  Perineal  body  is  made  up  of  muscular  insertions  and  origins 
(striped  and  unstriped),  and  fibrous  and  elastic  tissue.  Its  base  is 
covered  by  the  skin  lying  between  the  anus  and  vagina  ;  its  anterior  side 
is  in  great  part  below  the  level  of  the  posterior  vaginal  wall:  its 
posterior  side  lies  in  front  of  the  anterior  rectal  wall  and  anus ;  while 
laterally,  it  is  bounded  by  fat.  The  voluntary  muscles  passing  into  it 
are  the  sphincter  ani,  transversus  perinei,  bulbo-cavernosus,  and  levator 
aui  (fig.  7). 

This  Perineal  body  measures  about  li  inches  (4  cm.)  vertically,  the 
same  transversely,  and  f  in.  antero-posteriorly.  If  a  straight  line  be 
made  to  join  the  tip  of  the  coccyx  and  the  subpubic  ligament,  it  will 
just  clear  the  apex  of  this  structure. 


PERITONEUM.  39 

Its  functions  are  important,  but  have  been  both  exaggerated  and 
underrated.  It  gives  a  fixed  point  for  many  muscles,  prevents  pouching 
of  the  rectum  forwards,  and  strengthens  that  part  of  the  pelvic  floor 
which  has  no  posterior  bony  support. 

Its  special  significance,  however,  will  be  considered  further  on. 

At  present,  the  nomenclature  in  regard  to  the  "  Perineal  region"  is 
exceedingly  vague — the  term  Perineum  being  xised  in  this  general  sense 
by  accoucheurs,  especially  in  regard  to  the  tears  caused  by  parturi- 
tion. It  is  better  to  speak  of  these  as  tears  of  the  hymen,  fourchette,  and 
perineal  body,  instead  of  saying  "perineal  tears."  The  surface  between 
the  anal  and  vaginal  orifices  is,  strictly  speaking,  not  the  perineum  but 
the  "skin  over  the  base  of  the  perineal  body"  and  "the  fourchette." 

.     '  PERITONEUM. 

This  is  the  thin  serous  covering  of  the  concave  surface  of  the  pelvic  Pelvic 
floor  and  the  organs  resting  on  it.     A  knowledge  of  its  disposition  is  e^™  ° 
of  the  highest  importance  to  the  gynecologist.     This  is  best  considered 
as  follows. 

1.  The  Pelvic  Peritoneum  followed  in  a  Vertical  Mesial  Section  and 
from  before  backwards. — The  Peritoneum  of  the  anterior  abdominal  wall 
is  reflected,  at  a  point  a  little  above  the  symphysis  pubis,  on  to  the 
fundus  of  the  empty  bladder  (figs.  36  and  37).  It  passes  downwards 
over  the  posterior  surface  of  the  bladder,  from  which  it  crosses  on  to  the 
anterior  surface  of  the  xitems  at  a  point  about  the  level  of  the  os  inter- 
num.  From  this  it  passes  up  over  the  anterior  surface  of  the  uterus. 
Thus  there  is  formed  a  vesico-uterine  pouch,  containing  no  small  intestine  Vesico- 
either  when  the  bladder  is  in  systole  or  in  diastole  (figs.  36  and  37). 
When  the  bladder  has  the  Y- shape  in  pathological  anteflexion, 
the  peritoneum  passes  directly  backwards  across  the  fundus  of  the 
bladder  and  on  to  the  anterior  surface  of  the  uterus  at  or  below  the 
level  of  the  os  internum  (fig.  38).  There  is  thus  produced  a  utero- 
abdominal  pouch  (fig.  38). 

The  peritoneum  covers  the  whole  of  the  anterior  surface  of  the  uterus 
above  the  os  internum,  passes  over  the  fundus,  and  down  the  posterior 
surface  which  it  covers  almost  completely.  From  this  it  descends  still 
deeper,  on  to  the  posterior  aspect  of  the  posterior  vaginal  wall  for  about 
one  inch  (fig.  36).  The  depth  of  the  peritoneal  pouch  thus  formed 
behind  the  uterus  is  greater  on  the  left  side  than  on  the  right.  The 
amount  of  its  dip  varies.  In  one  section  by  Pirogoff  (fig.  39)  the  peri- 
toneum runs  down  on  the  posterior  vaginal  wall  till  within  about  an 
inch  from  the  vaginal  orifice.  This  extent  of  posterior  peritoneal 
duplicature  is  abnormal.  This  variation  in  depth  is  quite  evident  in 
sections  :  in  some  it  ends  at  the  level,  of  the  posterior  fornix  (fig.  37), 
while  in  others  it  is  seen  passing  as  deeply  as  has  been  already  described 


40  ANATOMY  OF  PELVIS. 

(figs.  36,  39).  This  descent  of  the  peritoneum  behind  the  uterus  is  of 
Pouch  of  the  highest  importance  practically,  and  forms  the  well-known  pouch  of 
Douglas.  Douglag  This  pouch  is  best  denned  as  follows: — Its  upper  lateral 
boundaries  are  the  utero-sacral  ligaments ;  its  anterior  boundary  is  the 
uppermost  inch  of  the  posterior  vaginal  wall  and  posterior  aspect  of  the 
supra- vaginal  portion  of  cervix ;  its  posterior  boundary  is  the  sacrum  and 
rectum,  covered  by  peritoneum.  It  is  the  lowest  part  of  the  peritoneal 
cavity,  and  from  its  relation  to  the  posterior  vaginal  wall  can  be 
explored  through  the  posterior  vaginal  fornix.  It  is  partially  filled  by 
intestine  when  the  uterus  lies  to  the  front,  which  becomes  displaced 
when  the  uterus  is  retroverted  or  retroflexed. 

Broad  2.   TJie  Disposition  of  the  Pelvic  Peritoneum  at  the  sides  of  the  Uterus  : 

Ligaments.  -grQa^  Ligaments.  —  At  the  sides  of  the  uterus,  the  peritoneum 
clothing  its  anterior  and  posterior  sxirfaces  passes  outwards  and  some- 
what backwards  to  the  sides  of  the  pelvis  in  front  of  the  sacro-iliac 
synchondrosis.  In  this  way  we  get  two  laminse  of  peritoneum  nearly 
in  apposition,  which  become  more  separated  at  their  junction  with  the 
pelvic  floor  and  sides  of  the  pelvis ;  the  space  between  the  laminse  is, 
at  its  outermost  part,  in  relation  to  the  obturator  internus  muscle 
(v.  Chap.  II.).  These  are  the  broad  ligaments  of  the  uterus. 

Immediately  within  their  upper  free  margin,  the  Fallopian  tubes 
are  placed.  That  part  of  the  free  margin  not  occupied  by  Fallopian 
tube  forms  the  infundibulo-pelvic  ligament  of  the  ovary  (figs.  20  and 
50).  Projecting  through  the  posterior  lamina  of  the  broad  ligament  is 
the  ovary,  covered  by  its  germ-epithelium.  The  ovarian  ligament  and 
parovarium  have  already  been  described  under  the  ovary  and  Fallopian 
tube. 

Between  the  layers  of  the  broad  ligament  lie  connective  tissue,  un- 
striped  muscle,  blood-vessels,  and  lymphatics.  According  to  M.  Guerin, 
the  broad  ligaments  enclose  a  small  space  shut  off  from  the  rest  of  the 
cellular  tissue  of  the  pelvis,  and  he  denies  that  as  yet  there  is  proof  of 
any  special  diagnosable  inflammatory  affection  of  the  broad  ligaments. 
Guerin  alleges  that,  by  inflation,  it  can  be  demonstrated  that  the  broad 
ligaments  are  thus  shut  off — a  fact  denied  by  other  observers. 

The -position  of  the  broad  ligaments  varies  according  to  that  of  the 

uterus.     When  the  uterus  is  normal  in  position,  i.e.,  lying  to  the  front, 

their  posterior  surfaces  look  upwards  and  somewhat  backwards,  and  they 

run  outwards  and  backwards  as  already  described.     Displacement  of  the 

uterus  backwards  causes  their  coincident  displacement,  and  in  pregnancy 

they  are  drawn  up  and  lie  almost  vertically.    Pathologically,  they  cicatrize 

after  inflammatory  attacks  and  cause  unilateral  deviations  of  the  uterus. 

Peritoneum      3.   The  Pelvic  Peritoneum  on  the  side  ivalls  of  the  Pelvis. — The  pelvic 

watts  of       peritoneum  clothes  the  side  walls  of  the  pelvis.     It  dips  down  least  at 

Pelvis.         the  sides  of  the  bladder,  and  most  at  the  utero-sacral  ligaments. 


FIG.  36. 

FROZEN  SECTION  showing  Peritoneum  (Fiirxt).  The  dotted  line  indicates  Peritoneum  in  this  and 
figs.  37-42.  a  Anus ;  b  Vagina  ;  c  Bladder  ;  d  Uterus  ;  e  below  pouch  of  Douglas  ;  /  Symphysis 
Pubis.  ({) 


FIG.  39. 
PERITONEUM  DIPPING  ABNORMALLY  DEEP  between  Rectum  and  Vagina  (Pirogoff). 


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CONNECTIVE  TISSUE.  41 

Although  the  pelvic  peritoneum  has  been  described  in  three  sections, 
it  must  of  course  be  kept  in  mind  that  it  is  a  continuous  membrane 
with  no  breaks  in  its  continuity. 

Some  special  facts  about  the  peritoneum  should  now  be  noted. 

1.  As  to  the  Bladder. — Over   the   bladder   and   anterior   abdominal  Relation  to 
wall,   the    peritoneum    is   easily   separable.       According    to    Spiegel- an(j 
berg,   posteriorly   it   is   closely   blended   with   the    uterus    above   theRectunu 
os  internum,  below  this  quite  loosely  attached.      When  the  bladder 

is  distended,  the  peritoneum  is  stripped  off  the  lower  part  of  the 
anterior  abdominal  wall  to  an  extent  varying  with  the  distention 
(fig.  42).  During  parturition,  the  peritoneum  is  drawn  off  the 
bladder  (fig.  41)  (Hart). 

2.  As  to  the  Rectum. — Its  upper  part  is  completely  invested  by  peri- 
toneum ;  the  second  part  is  only  partially  covered,  i.e.,  the  peritoneum 
gradually  leaves  the  rectum,  quitting  first  the  posterior  surface,  then 
the   sides,  and    finally   passing  from   the    anterior   surface  on   to   the 
posterior  vaginal  wall. 

See  also  Chapter  II.  on  The  Sectional  Anatomy  of  the  Female  Pelvis, 
and  especially  Chapter  III.,  p.  57. 

Practical  Points. — Although  the  vesico-uterine  pouch  can  be  reached  Peritoneum 
by  a  transverse   incision  through  the  anterior  fornix,  it  will  not   be  to  opera- 
cut  into  in  operations  on    the  anterior  vaginal    wall.     In   the   upper tions- 
third  or  so  of  the  posterior  vaginal  wall  the  peritoneum  may  be  opened 
into.     This  has  indeed  been  done  by  the  most  skilful  operators,  but  the 
risks  attending  it  are  not  so  considerable  as  usually  alleged,  especially 
when   asepsis    is    secured.      When    the    fingers    are    passed    into    the 
posterior  fornix  vaginse,  only  about  ^  inch  of  tissue  intervenes  between 
them 'and  the  peritoneum.     The  possibility  of  there  being  a  deep  dip  of 
the  peritoneum,  as  shown  at  fig.  39,  should  not  be  forgotten  in  opera- 
tions on  the  posterior  vaginal  wall. 


CONNECTIVE    TISSUE    OF    PELVIS. 

By  this  we  understand  (I.)  the  Fascia  described  so  elaborately 
by  the  human  anatomist  as  the  Pelvic  Fascia;  and  (II.)  the  loose 
Connective  Tissue  padding  the  interstices  between  the  muscles, 
lying  round  the  cervix  uteri,  and  spreading  out  beneath  the  pelvic 
peritoneum. 

I.  The  Pelvic  Fascia  of  the  anatomist  is  carefully  described  in  the  Pelvic 
ordinary  systematic  and  dissecting-room  manuals,  to  which  the  student Fascia- 
is  therefore  referred  (v.  also  p.  8  and  Chap.  II.). 

II.  The  loose  connective  tissue  found  lying  subperitoneally,  surround- Pelvic  Con- 
ing the  cervix  uteri  and  spreading  out  between  the  layers  of  the  broad  Tissue. 


42  ANATOMY  OF  PELVIS. 

ligament,  is  of  the  highest  importance  pathologically,  as  in  it  and 
in  the  pelvic  peritoneum  occur  those  inflammatory  exudations  so 
common  in  women.  Of  late  years  our  knowledge  of  the  disposition 
of  this  tissue  has  been  rendered  much  more  accurate,  and  accordingly 
•  our  discrimination  of  pelvic  inflammatory  attacks  made  much  more 

precise. 

Methods  of  The  distribution  and  relations  of  the  pelvic  connective  tissue  may  be 
studying  stu(jjeci  jn  various  ways.  The  most  valuable  information  is  obtained  by 
considering  sections  of  frozen  or  spirit-hardened  pelves.  This  gives  the 
precise  position  of  the  tissue,  its  amount,  and  distribution.  Another 
valuable  method  of  investigation  is  to  inject  air  beneath  the  peritoneum, 
between  the  layers  of  the  broad  ligament,  and  at  other  points.  By  this 
we  learn  the  varying  attachments  of  the  pelvic  peritoneum  to  the  sub- 
jacent tissue,  and  the  lines  of  cleavage,  as  it  were,  of  the  pelvic  con- 
nective tissue  along  which  pus  will  burrow.  Instead  of  air  we  may 
inject  plaster  of  Paris  or  water ;  plaster  of  Paris  will  be  found  the  most 
useful. 

We  therefore  consider — 

a.  Kesults  obtained  by  the  injection  of  water,  air,  plaster  of  Paris  ; 
I.  Results  obtained  by  section. 

a.  Results  obtained  by  injections  of  water,  air,  or  plaster  of  Paris. 

The  best  summary  of  these  results  is  given  by  Bandl,  to  whom  on 
this  point  we  are  indebted  for  much  valuable  information. 

Connective      Konig  in  his  researches  employed  the  bodies  of  women  who  had  died 
vestigated  a  short  time  after  labour  from  non-puerperal  diseases,  and  injected  air 

by  injec-     or  water.     The  following  briefly  are  his  results  • — 
tions.  ,..  x    TT7.  .    . 

(1.)  Water  injected  between  the  layers  of  the  broad  ligament,  high 

up  in  front  of  the  ovary,  passed  first  into  the  tissue  lying  at  the  highest 
part  of  the  side  wall  of  the  true  pelvis.  It  then  passed  into  the  tissue 
of  the  iliac  fossa,  lifting  up  the  peritoneum,  and  followed  the  course 
of  the  psoas,  passing  only  slightly  into  the  hollow  of  the  iliac  bone. 
Lastly,  it  separated  the  peritoneum  from  the  anterior  abdominal  wall 
for  some  little  distance  above  Poupart's  ligament,  and  from  the  true 
pelvis  below  it. 

(2.)  On  injection  beneath  the  base  of  the  broad  ligament  to  the 
side  and  in  front  of  the  isthmus,  the  deep  lateral  tissue  became 
filled  first;  then  the  peritoneum  became  lifted  up  from  the  anterior 
part  of  the  cervix  uteri.  The  separation  passed  thence  first  to 
the  tissue  near  the  bladder,  and  ultimately  the  fluid  passed  along 
the  round  ligament  to  the  inguinal  ring.  There  it  separated  the 
peritoneum  along  the  line  of  Poupart's  ligament,  and  passed  into  the 
iliac  fossa. 


CONNECTIVE   TISSUE.  43 

(3.)  An  injection  at  the  posterior  part  of  the  base  of  the  broad  liga- 
ment filled  the  corresponding  tissue  round  Douglas'  pouch,  and  then 
passed  on  as  described  at  (1.). 

Schlesinger  has  followed  out  these  results  in  more  elaborate  researches. 

b.  Results  obtained  by  section. 

The  Sectional  Anatomy  of  the  Pelvis  has  now  become  a  subject  of 
such  importance  that  it  demands  consideration  in  a  separate  chapter. 
The  student  will  find  at  pp.  46,  47,  reference  made  specially  to  the  dis- 
tribution of  the  connective  tissue. 


CHAPTER  II. 

THE  SECTIONAL  ANATOMY  OF  THE  FEMALE  PELVIS. 

LITERATURE. 

Barbour,  A.  H.  /'.—Spinal  Deformity  in  Relation  to  Obstetrics  :  \V.  &  A.  K.  Johnston, 
Edinburgh,  1884.  The  Anatomy  of  Labour  as  exhibited  in  Frozen  Sections :  W.  &  A.  K. 
Johnston,  Edinburgh,  1889.  Braune— Topographisch-anatomischer  -Atlas,  Zweite 
Auflage  :  Veit  &  Co.,  Leipzig,  1872.  Dwight— Frozen  Sections  of  a  Child  :  Wood  & 
Co.,  New  York,  1883.  Hart,  D.  Berry— Atlas  of  Female  Pelvic  Anatomy :  W.  &  A.  K. 
Johnston,  Edinburgh,  1884.  Supplement  to  Atlas  of  Female  Pelvic  Anatomy  : 
W.  &  A.  K.  Johnston,  Edinburgh,  1884.  Legendre— Anatomic  Homolographique  : 
Paris,  1868.  His — Ueber  Praparate  zum  Situs  Viscerum,  etc.  :  Arch,  fur  Anat., 
1878.  Die  Lage  der  Eierstocke,  Arch,  fur  Anat.  1881.  Luschka— Die  Anatomie  des 
menschlichen  Beckens :  Tubingen,  1864.  Pirogoff—  Anatome  Topographica  sec- 
tionibus  per  corpus  humanum  congelatum,  etc.  :  Petropoli,  1859.  Rucdingcr — Topo- 
graphisch  - hirurgische  Anatomic  des  Menschen  :  Stuttgart,  1873.  Simpson  and 
Hart— The  Relation  of  the  Abdominal  and  Pelvic  Organs  in  the  Female  :  "W.  &  A.  K. 
Johnston,  Edinburgh,  1881.  Veit — Die  Anatomie  des  Beckens :  Enke,  Stuttgart, 
1887.  Pirogoff  and  Braune's  Atlases  are  the  great  storehouse  of  Sectional  Anatomy. 
Accounts  of  the  method  of  freezing  are  given  by  Braune,  Barbour,  and  Simpson  and 
Hart. 

WHILE  dissections  are  valuable  in  ascertaining  the  anatomy  of  any 
region,  it  must  be  remembered  that  they  involve  displacement  of 
relations  and  therefore  may  lead  into  error  or  exaggeration.  These 
may  be  corrected  and  additional  accuracy  obtained  by  making  sections 
of  frozen  bodies  or  parts  of  them.  If  a  body  or  a  pelvis  be  covered  with 
mackintosh  and  embedded  in  a  mixture  of  salt  and  finely  pounded 
ice  or  snow,  it  will  in  three  or  four  days  become  as  firm  and  solid  as 
marble,  and  may  then  be  sawn  in  any  direction  necessary.  Tracings 
of  the  sawn  surface  may  be  made  while  it  is  still  frozen ;  and  in  this 
way  an  accurate  and  trustworthy  drawing  may  be  obtained  on  which 
valuable  measurements  can  be  made. 

We  have  said  that  the  sections  may  be  sawn  in  any  direction,  but 
usually  they  are  made  in  special  and  definite  lines  as  follows  : — 

(1.)  Sagittal  Mesial,  i.e.  parallel  to  the  sagittal  suture  so  that  the 
body  or  pelvis  is  divided  into  right  and  left  halves ; 

(2.)  Sagittal  Lateral,  i.e.  parallel  and  to  one  or  other  side  of  the 
sagittal  mesial  plane; 

(3.)  Transverse  or  Horizontal,  i.e.  at  right  angles  to  the  long  axis  of 
the  body,  and  with  surfaces  upper  and  lower ; 


PLATE  I. 


FIG.  2. 


POSITION   OF   UTERUS  AND  OVARIES. 
FIG.  1.  Sagittal  Mesial  Section  of  Pelvis  (Hart). 
FlO.  2.  Fundus  Uteri  and  Ovaries— Seen  through  the  Pelvic  Brim  (His). 


SAGITTAL   LATERAL  SECTION.  45 

(4.)  Coronal,  i.e.  parallel  to  the  coronal  suture  dividing  the  body  or 
pelvis  into  anterior  and  posterior  portions  with  surfaces  anterior  and 
posterior ; 

In  sections  of  the  pelvis  alone,  the  axis  of  the  brim  is  taken  instead  of 
the  long  axis  of  the  body.  We  have  therefore  the  following  : — 

(5.)  Axial  coronal,  i.e.  a  section  cut  parallel  to  the  axis  of  the  brim 
and  from  side  to  side,  with  sawn  surfaces  anterior  and  posterior ; 

(6.)  Axial  transverse,  i.e.  at  right  angles  to  the  axis  of  the  brim  and 
with  surfaces  therefore  upper  and  lower. 

We  now  take  up  the  consideration  of  certain  special  sections. 

1.   Sagittal  Mesial  Section. 

Plate  I.,  fig.  1,  shows  a  frozen  sagittal  mesial  section  of  the  pelvis  with  Sagittal 
the  uterus  in  position,  the  bowel  and  bladder  naturally  empty  and  the  sc^,n> 
small  intestine  removed  from  the  pouches  so  as  to  display  the  Fallopian 
tube  and  ovary.  This  section  brings  out  the  following  facts  :  the  uterus 
is  not  mesial  but  displaced  somewhat  to  the  left ;  the  empty  bladder 
is  Y-shaped  in  sagittal  mesial  section  ;  the  urethra,  vagina,  and  rectum 
are  nearly  parallel  to  one  another  and  to  the  conjugate  of  the  brim ; 
the  anus  cuts  these  axes  at  right  angles.  The  intestines  have  been 
removed  from  the  Pouch  of  Douglas  and  vesico-uterine  pouch.  The 
nearness  of  the  anterior  abdominal  wall  to  the  promontory  of  the  sacrum 
is  well  shown.  The  Perineal  body  is  seen  in  section,  and  it  should  be 
noted  that  the  greater  part  of  it  lies  below  the  Hymen.  Those 
Gynecologists  who  exaggerate  its  functions  usually  draw  it  as  being 
entirely  behind  the  lower  part  of  the  posterior  vaginal  wall.  Plate  I. 
and  fig.  23  shows  that  it  does  not  do  this.  The  student  should  note  the 
peritoneal  relations. 

Plate  I.  also  shows  the  relations  of  the  Fallopian  tube  and  ovary.  When 
freshly  cut,  the  intestines  filled  the  peritoneal  cavity  ;  but  after  the 
section  had  been  hardened  in  spirit,  these  were  carefully  lifted  out  so 
as  to  expose  the  ovary  and  Fallopian  tube.  The  ovary  lies  with  its 
long  axis  vertical,  as  His  has  pointed  out.  The  preparation  bears  out 
his  views  completely  with  regard  to  the  position  of  the  ovaries,  for  on 
the  other  side  of  the  body  the  ovary  had  its  long  axis  somewhat 
transverse ;  and  he  has  found  that  when  the  uterus  was  laterally 
displaced  the  ovary  of  the  side  towards  which  the  uterus  was  displaced 
lay  vertical  while  the  other  ovary  was  somewhat  transverse.  In  this 
cadaver  the  uterus  lay  to  the  left  side  and  it  is  the  left  ovary  which 
has  its  long  axis  vertical.  The  Fallopian  tube  does  not  form  a  loop 
enclosing  the  ovary  as  His  found  in  his  specimens  (Plate  I.  fig.  2). 

2.   Sagittal  Lateral  Section.  Sagittal 

By  this  section  a  specially  valuable  view  is  obtained.     Fig.  43  shows  Section. 


46  ANATOMY  OF  PELVIS. 

a  drawing  of  a  section  at  the  junction  of  the  uterus  and  broad  ligaments  ; 

in  it,  although  the  pubes  is  divided  mesially,  the  pelvic  contents  are  cut 

to  one  side  of  the  mesial  plane.  It  should  be  noted  that  the  amount  of 
Connective  retropubic  tissue  is  less  than  in  the  sagittal  mesial  one  ;  that  at  the  June- 
Tissue  of  tion  of  the  broad  ligaments  with  the  uterus  there  is  a  large  amount  of 
Laments,  tissue  with  large  blood-vessels ;  and  specially  that  the  finger  placed  in 

the  lateral  fornix  vaginas  touches  the  base  of  the  broad  ligament  there. 


FIG.  43. 

SAGITTAL  MESIAL  SECTION  OF  PELVIS  cutting  at  Junction  of  Broad  Ligament  and  Uterus. 
<i  Vagina  with  its  walls  separated  ;  b  Bladder  ;  c  Symphysis ;  d  Broad  ligament ;  e.  Ovary  ;  /  Fallo- 
pian Tube.     In  this  specimen  the  Uterus  was  laterally  displaced. 

This  fact  is  valuable  as  to  diagnosis.  On  section,  the  boundaries  of  the 
space  between  the  broad  ligaments  are  seen  :  superiorly  the  cut  section 
of  the  Fallopian  tube,  anteriorly  and  posteriorly  the  peritoneum,  and 
inferiorly  the  vaginal  fornix.  The  assertion  by  Guerin  and  Le  Bee  as 
to  the  insignificance  of  the  tissue  here  is  not  borne  out. 

Sections  made  nearer  the  side  pelvic  wall  display  specially  the  lessen- 


PLATE   II. 


TRANSVERSE  SECTION. 


47 


ing  tissue  between  the  layers  of  the  broad  ligaments  and  show  sections 
of  the  ovary. 

3.   Transverse  or  Horizontal  Section. 

These  give  results  confirming  those   above   stated.      Pirogoff  gives  Pelvic  Con- 
several  sections  in  his  Atlas,  but  these  are  not  clearly  defined  in  their  Tissul— as 
connective  -  tissue  relations.      Freund   has  published   a  very  valuable seen. in 
series  of  preparations  in  his  recently  issued  gynakologische  Klinik.     The  Section.  ' 
most  valuable  sections  are  those  at  the  level  of  the  supra-vaginal  portion 
of  the  cervix,   which  show  the  tissue  lying  here  all  round  it.      In  fig. 
44  we  show  a  section  from  Ruedinger,  where  the  retropubic  fat  and 
ischiorectal  cavities  are  well  shown. 


FIG.  44. 

TRANSVERSE  SECTION  OF  FEMALE  PELVIS  AT  PLANE  OF  HIP-JOINTS  (Ruedinger). 
ft  Coccyx;  b  Ischioreetal  fossa;  c  Rectum  ;  d  Vagina;   e  Bladder;  /Retropubic  fat;  g  Hip-joint. 


This  is  the  best  place  to  draw  special  attention  to  what  Virchow  first  Parametric 
termed  the  parametric  tissue.     By  this  term  he  meant  the  loose  fatless   1! 
tissue  ('8  in.  thick),  with  abundant  blood-vessels  and  lymphatics,  sur- 
rounding "  the  lower  portion  of  the  uterus  and  the  upper  portion  of  the 
vagina"   (Spiegellerg).     This  is  the   parametric  tissue  proper.      Some 
extend  the  meaning  of  the  term  parametric  tissue  so  as  to  include  all 
the  connective  tissue  in  the  pelvis. 


48 


ANATOMY  OF  PELVIS. 


Coronal 
Section. 


4.  Coronal  Section. 

Plate  II.  fig.  1,  shows  a  coronal  section  of  the  pelvis  passing  through 
the  base  of  The  sacrum  and  the  great  trochanter.  We  note  that  the 
sacro-iliac  joint  runs  from  above  downwards  and  inwards.  The  body  of 
the  sacrum  bulges  downwards,  and  the  ischial  tuberosity  projects  inwards 
so  that  the  side  wall  of  the  pelvis  is  not  straight :  both  of  these  are 
abnormalities.  The  anterior  portion  of  the  sacro-sciatic  notch  is  seen. 


FIG.  45. 

CORONAL  FROZEN  SECTION  OF  PELVIS  (Ruedinger). 
a  Fundus  uteri ;  6  Bladder  ;  d  Labium  minus  ;  e  Labium  roajus. 

The  levator  ani  is  seen  arising  from  the  pelvic  fascia  over  the  obturator 
internus,  and  passing  down  to  be  inserted  into  the  perineal  body.  The 
muscles  of  the  perineum  are  also  exposed.  The  body  of  the  retroverted 
uterus  is  seen  in  great  part,  and  lies  perpendicular  to  the  horizon  ;  the 
frozen  intestines  have  been  removed  so  as  to  expose  the  fundus  ;  the  left 
Fallopian  tube  and  round  ligament  have  been  divided  as  they  pass  for- 
wards from  the  uterus.  The  left  ovary  has  been  partially  cut  across, 
and  the  removal  of  the  intestines  has  exposed  it  entirely.  Some  cellular 


PLATE  III. 


Obturator  inlernus 


-Pouch,  or  Douglas 


FIG.  1. 


FIG.  2. 


AXIAL  CORONAL  SECTIONS   OF  PELVIS—  Seen  from  behind  (Hart). 


"W  VA  K  Jchn«ton    EdmVurJh  t  London 


AXIAL    CORONAL   SECTION.  49 

tissue  is  also  exposed  in  the  broad  ligament ;  and  there  is  some  fatty 
cellular  tissue  external  to  this  and  continuous  with  the  sub-peritoneal 
fatty  tissue  which  lies  external  to  the  ovary  and  in  the  region  of  the 
sacro-sciatic  notch.  The  uterus  in  this  cadaver  lay  perpendicular  to  the 
horizon,  and  the  ovary  has  the  vertical  position  already  described  as 
a  common  one.  The  connective  tissue  between  the  bladder  and  the 
rectum  is  well  seen  as  also  its  continuity  with  that  in  the  broad  liga- 
ment. This  section  explains  clearly  how  a  cellulitis  when  suppurated 
may  open  into  the  vagina  or  pass  through  the  sciatic  notch  to  the  hip. 
The  levator  ani  and  transversus  perinei  ending  in  the  perineal  body 
are  clearly  seen. 

This  section  of  the  sacral  plane  does  not  show  the  bite  or  joggle 
described  by  Matthews  Duncan ;  but  it  is  well  seen  in  the  next  figure. 

Plate  II.  fig.  2,  shows  a  coronal  section  f  inch  behind  the  preceding. 
In  the  bony  pelvis  we  note,  as  has  been  said,  that  the  sacro-iliac 
joint  shows  the  bite  or  joggle.  The  spine  of  the  ischium  has  been 
divided  where  it  gives  origin  to  the  levator  ani ;  the  tuberosity  is 
cut  through  in  its  posterior  part,  where  it  gives  origin  to  the  muscles. 
The  levator  ani  is  seen  arising  from  the  ischial  spine  and  passing  down- 
wards to  be  inserted  into  the  rectum  at  the  external  sphincter.  Exter- 
nal to  it  lies  the  ischio-rectal  fossa,  which  extends  upwards  as  far  as  the 
ischial  spine ;  internal  to  it,  a  well-marked  layer  of  the  pelvic  fascia  is 
displayed.  The  uterus  has  been  sliced  across  from  the  ovarian  ligament 
to  below  the  utero-sacral  ligament ;  the  intestines  seen  above  it  occupy 
the  highest  part  of  the  pouch  of  Douglas.  The  peritoneum  of  the  pouch 
of  Douglas  has  been  cut  across  in  two  places, — where  it  covers  the  body 
of  the  uterus  about  the  level  of  the  ovarian  ligaments,  and  also  1  -3  cm. 
(\  in.)  above  the  bottom  of  the  pouch  of  Douglas. 

We  observe  in  this  section  the  boundaries  of  the  ischiorectal  fossa, 
and  the  continuity  of  the  tissue  in  the  broad  ligament  with  that  in  front 
of  the  sacrum. 

At  fig.  45  is  shown  the  relations  of  the  pelvic  organs  in  Ruedinger's 
coronal  section  of  a  female  cadaver.  The  complete  section  is  given  in 
Plate  V.  and  will  be  referred  to  when  we  have  to  consider  the  relations 
of  the  organs  with  regard  to  the  examination  of  the  abdomen. 

5.  Axial  Coronal  Section  of  Pelvis. 

Plate  III.  fig.  2,  is  an  axial  coronal  section  made  1^  inch  behind  the  Axial 
pubes  and  passing  through  the  hip  joints.     This  pelvis  was  not  normal,  Coronal 
as  there  was  a  cellulitis  of  the  left  broad  ligament  and  a  displacement 
of  the  bladder  to  the  right  side.     The  section  is  viewed  from  behind. 
Owing  to  a  slight  distention  of  the  bladder  the  uterus  lay  in  the  axis  of 
the  brim  and  has  been  divided  coronally.      The  left  broad  ligament 


50  ANATOMY  OF  PELVIS. 

has  been  divided  similarly  so  that  its  side  relations  to  the  obturator 
internus  are  displayed.  The  vagina  is  a  crescentic  slit,  the  side  limits 
of  the  vaginal  portion  of  the  cervix  being  marked  x  x.  The  levatores  ani 
are  seen  springing  from  the  pelvic  fascia  and  curving  downwards  and 
inwards  below  the  rectum.  We  see  that  here  the  boundaries  of  the 
ischiorectal  fossa  are  gluteus  maximus,  below ;  levator  ani,  above  and  to 
the  inner  side ;  and  obturator  internus,  above  and  to  the  outer  side.  On 
the  right  side,  the  ureter  has  been  cut  as  it  lies  in  the  bladder  wall : 
it  lies  |-  inch  from  the  vagina.  On  the  left  side  it  is  about  one  inch 
from  the  vagina.  This  section  exhibits  the  side  relations  of  the  broad 
ligament,  the  continuity  of  the  connective  tissue  between  the  layers  of 
the  broad  ligament  with  that  in  front  of  the  iliacus  muscle,  and  the 
accurate  packing,  as  it  were,  of  the  abdominal  viscera. 

PI.  III.  fig.  1,  gives  a  section  similar  in  direction  to  the  preceding, 
but  about  one  inch  farther  back  so  that  it  grazes  the  posterior  surface 
of  the  uterus. 

The  Pouch  of  Douglas  is  cut  into  at  one  part.  The  left  broad  liga- 
ment is  shortened  by  the  cellulitis  already  mentioned.  The  ischiorectal 
fossa  is  seen  at  its  most  posterior  part  and  is  very  small,  being  roofed  in 
by  the  levator  ani  and  its  floor  being  formed  by  the  gluteus  maximus. 
The  divided  ureters  are  seen  lying  in  the  loose  fatty  tissue  outside  the 
broad  ligaments. 


CHAPTER   III. 

THE  POSITION  OF  THE  UTERUS  AND  ITS  ANNEXA,  AND 
THE  RELATION  OF  THE  SUPERJACENT  VISCERA. 

LITERA  TDRE. 

Bandl — Ueber  die  normale  Lage  und  das  normale  Verhalten  des  Uterus  und  die  patho- 
logisch  -  anatomischen  Ursachen  der  Erscheinung  Anteflexio :  Arch.  f.  Gynak., 
Bd.  XXII.,  S.  408.  Braune — Topograph.  Anatom.  Atlas,  Zweite  Auflage  :  Leipzig, 
Veit  &  Co.,  1872.  Claudius — On  the  Position  of  the  Uterus :  Med.  Times  and 
Gazette,  1865,  p.  5.  Crede — Beitrage  zur  Bestimmung  der  normalen  Lage  der 
gesunden  Gebarmutter :  Archiv  f.  Gynak ologie,  Bd.  I.,  S.  84.  foster — A  Contribu- 
tion to  the  Topographical  Anatomy  of  the  Uterus  and  its  Surroundings  :  Am.  J.  of 
Obst.  XIII.,  p.  30.  Hart,  D.  B.—  Atlas  of  Female  Pelvic  Anatomy  :  W.  &  A.  K. 
Johnston,  Edinburgh,  1884.  See  also  Supplement  to  Atlas.  Hasse — Beobachtungen 
liber  die  Lage  der  Eingeweide  im  weiblichen  Beckeneingange :  Archiv  f.  Gynak. 
Bandviii.,  S.  402.  His — Ueber  Praparate  zum  Situs  Viscerum  u.s.u. :  Arch,  fiir  Anat., 
1878.,  S.  53.  And  Die  Lage  der  Eierstocke  in  der  weiblichen  Leiche  :  Arch,  fiir 
Anat.,  1881,  S.  398.  Pirogoff — Anatome  Topograph.  etc. :  Petropoli,  1859.  Sappey — 
Traite  d'  Anatomie  Descriptive :  Paris,  1873.  Schrocdci — Handbuch  der  Krankheiten 
der  weiblichen  Geschlectsorgane  :  Leipzig,  1879.  Schultze — Die  Pathologie  und 
Therapie  der  Lageveranderungen  der  Gebarmutter  :  Berlin,  1881.  Symington,  J. — 
The  Topographical  Anatomy  of  the  Child  :  Edinburgh,  Livingstone,  1887.  An 
admirable  account  of  the  subject  will  be  found  in  Van  de  Warker's  articles  on  a 
study  of  the  Normal  Movements  of  the  Unimpregnated  Uterus  :  N.  Y.  Medical 
Journal,  XXL,  p.  337.  And  on  the  Normal  Position  and  Movements  of  the  Unim- 
pregnated Uterus :  Am.  J.  of  Obst.,  Vol.  XI.,  p.  314. 

THE  amount  of  literature,  chiefly  French  and  German,  on  this  subject  is 
much  too  extensive  even  to  be  mentioned  here,  for  the  position  of  the 
uterus  has  given  rise  to  much  discussion.  This  is  partly  due  to  the 
inherent  difficulty  of  accurate  clinical  observations,  to  the  erroneous 
opinions  advanced  by  many  eminent  anatomists,  and  to  arbitrary 
demands  as  to  the  normal  uterine  position  made  by  gynecologists  with 
strong  opinions  011  anteversion. 

Thus,  in  the  well-known  works  of  Braune,  Luschka,  Cruveilhier,  and  Difference 

Henle,  the  uterus  is  figured  from  actual  sections  as  normal  with  the in  °pinions 

as  to  posi- 

f und  us  in  the  hollow  of  the  sacrum,  i.e.,  retroposed.  Claudius  oftion  of 
Marburg,  also  an  anatomist,  is  uncompromising  on  this  point.  He  states, 
indeed,  that  the  uterus  is  normal  only  when,  with  its  broad  ligaments, 
its  posterior  surface  touches  the  sacrum  as  closely  as  the  lungs  do  the 
ribs  (fig.  46).  Now,  almost  all  gynecologists  agree,  from  clinical  observa- 
tion, that  the  body  of  the  uterus  lies  over  on  the  bladder,  with  the  os 


52  ANATOMY  OF  PELVIS. 

ten  looking  more  or  less  back.  This  divergence  of  opinion  is  extra- 
oS  nary  and  it  leads  to  this  interesting  practical  observation,  that  what 
the  anatomist  considers  a  uterus  normal  in  position,  the  gynecolog^ 
believes  to  be  abnormal.  That  is,  the  retroverted  uterus-considered 
normal  in  cadavera  by  the  anatomist-is,  when  found  m  the  living 
subject,  replaced  by  the  gynecologist  so  that  it  lies  with  its  body  over 

the  bladder.  „        ,.    .,, 

There  can  be  no  doubt  that  the  uterus  lies  normally  to  the  front  with 
its  anterior  surface  resting  on  the  bladder.    Great  refinement  is  exercised, 


FIG.  46. 

TRANSVERSE  SECTION  of  PELVIS  in  line  of  PYRIFOKM  MUSCLES  (Luichka).  The  Peritoneum  has  been 
removed  on  the  right  side,  a  3d  Sacral  Vertebra ;  6  Bladder ;  c  Ureter ;  d  Levator  Ani ;  e  Rectum  ; 
/  Anterior  Layer  of  Broad  Ligament ;  g  Uterus  ;  h  Pyriform  Muscle.  Note  that  here  the  uterus 
is  retroverted,  and  the  pouch  of  Douglas  without  intestine. 

quite  unnecessarily,  by  many  gynecologists  in  settling  what  they  believe 
to  be  the  exact  angle  which  the  long  axis  of  the  uterus  should  make  with 
the  horizon,  when  a  woman  is  in  the  erect  posture ;  and  this  refinement 
has  been  greatly  stimulated  by  the  mechanical  treatment  of  what  is  known 
by  many  as  anteversion  of  the  uterus. 

In  treating  of  this  vexed  question,  we  shall  consider — 

1.  The  normal  form  and  position  of  the  uterus ; 

2.  The  local  divisions  of  the  pelvic-floor  peritoneum  as  viewed  through 
the  pelvic  brim,  and  the  position  of  the  uterus  and  its  annexa ; 

3.  The  physiological  changes  in  the  position  of  the  uterus ; 


POSITION  OF  UTERUS. 


53 


4.  The  relation  of  the  small  intestine  to  the  pelvic  floor  and  to  the 
uterus  and  its  annexa. 

THE    NORMAL    FORM    AND    POSITION    OP    THE   UTERUS. 

The  question  of  the  form  of  the  uterus  we  consider  only  in  the  limited  Normal 
aspect  of  the  angular  relation  of  the  long  axis  of  the  uterus  to  the  long  uterus, 
axis  of  the  cervix.     These  are  not  in  the  same  straight  line,  but,  when 
the  bladder  and  rectum  are  empty,  lie  at  an  obtuse  angle  of  varying 
value.     This  angle  is  more  open  in  multiparous  women  (fig.  25),  than 
in  nulliparse  (fig.  47). 

The  question  as  to  whether  in  the  normal  uterus  the  cervix  and  body 


FIG.  47. 

DIAGKAM  to  show  Normal  Form  and  Position  of  VIRGIN  UTERUS  (Schultze). 

are  in  the  same  straight  line  or  meet  at  an  angle  opening  anteriorly,  is 
much  disputed  and  by  no  means  easy  to  settle.  Bimanually,  the  normal 
uterus  is  fairly  often  found  anteflexed,  but  the  question  arises  whether 
the  Bimanual  examination  has  not  brought  about  or  at  any  rate  exag- 
gerated the  anteflexion.  Bandl  asserts  that  when  the  uterus  is  removed 
and  examined  post  mortem,  anteflexion  is  rarely  found,  the  normal  uterine 
axis  being  straight.  It  should  be  remembered  however  that  the  removal 
of  the  uterus  from  the  body  involves  the  cutting  of  the  utero-sacral 
ligaments  and  the  absence  of  intra-abdominal  pressure,  i.e.,  removes  the 


54 


ANATOMY  OF  PELVIS. 


conditions  in  the  living  subject  which  keep  up  "physiological  ante- 
flexion";  so  that  a  uterus  somewhat  anteflexed  during  life  may  be 
straightened  by  removal  post  mortem.  The  best  way  to  ascertain  the 
existence  of  anteflexion  in  the  living  woman  is  to  use  simple  vaginal 
examination.  The  question  really  is  as  to  the  normal  form  of  the  uterus 
in  the  living  woman  with  the  peritoneal  folds  intact  and  intra-abdominal 
pressure  in  action.  Under  these  conditions  there  is  a  normal  degree  of 
anteflexion  which  is  called  "  Physiological  anteflexion,"  in  contrast  with 


FIG.  48. 

SECTION  of  PELVIS   showing  UTERUS  driven  back  by  distended  Bladder,  and  Peritoneum  disturbed 
ten).     Thit  n  not  a  normal  condition  of  parts  l>y  any  means. 

Schultze's  "Pathological  anteflexion,"  so  commonly  caused  by  utero-sacral 
cellulitis  (v.  also  chap,  on  Displacements  of  the  Uterus). 

w3n  of      The  P^ion  of  the  uterus,  with  empty  bladder  and  rectum,  is  such 
;  lies  with  its  anterior  surface  touching  the  posterior  aspect  of  the 


POSITION  OF   UTERUS. 


55 


bladder,  no  intestine  usually  intervening ;  the  os  externum  uteri  looks 
downwards  and  backwards  :  and  the  uterus  is  slightly  twisted  as  a  whole 
on  its  long  axis,  so  that  the  uterine  end  of  the  right  Fallopian  tube  is 
nearer  the  symphysis  than  that  of  the  left.  We  have  expressly  said 
with  bladder  and  rectum  empty.  According  to  Schultze,  the  long  axis 
of  the  uterus  is  nearly  parallel  to  the  horizon.  This  is  probably  exag- 
gerated, as  Schultze's  researches  were  conducted  in  a  way  that  certainly 


FIG.  49. 

SECTION  of  FEMALE  CADAVER  (Pirogojf). 

a  Vagina ;  6  Uterus ;  c  Bladder. 
Note  Bladder  in  diastole,  Uterus  parallel  to  horizon,  and  shallow  dip  of  Douglas'  Pouch. 

anteverted  the  uterus  unduly  (figs.  25  and  47).  Many  authors  figure 
the  uterus  nearly  vertical  to  the  horizon,  for  this  purpose  distending  the 
bladder  until  the  uterus  is  elevated  to  what  they  consider  the  proper 
angle  (fig.  48).  It  is  needless  to  say  how  absurd  this  is.  Kohlrausch's 


56  ANATOMY  OF  PELVIS. 

diagram,  so  often  quoted  in  support  of  this  allegation,  really  shows,  if  it 
show  anything,  the  position  of  the  uterus  when  the  bladder  is  well 
distended.  The  student  should  note  this  point,  as  Kohlrausch's  section 
is  the  favourite  diagram  of  those  who  treat  as  pathological  what  is  really 
a  normal  uterus.  Fig.  49,  from  Pirogoff,  shows  a  frozen  section  support- 
ing Schultze's  contention. 


J. 


FIG.  50. 

FEMALE  PELVIS  and  CONTENTS  viewed  through  the  Pelvic  Brim  (Hasse). 
y.  Para vesical  Pouch  ;  u  Uterus;  o  Ovary  ;   t  Fallopian  Tube;  d  Pouch  of  Douglas; 
v~?,         • V?*        ,  Dou8las '»  l  P  Infundibulo-pelvic  Ligament ;   I  r  Bound  Ligament ;  p  u 
Powtion  of  Ureter  ;  I  o  Ovarian  Ligament ;  r  Rectum  ;  c  Colon. 

[t  is  important  to  know  how  results  as  to  the  uterine  position  have 
been  obtained.     The  chief  methods  are  as  follows  :— 

a\  7}  *  .      . 

•)    By  frozen,   spint-hardened,    or    chromic-acid  sections.  —  Results 
tained  in  this  way  are  valuable,  if  we  make  allowance  for  some  post- 
nortem  change  in  the  uterine  position  not  yet  thoroughly  understood. 


POSITION  OF  UTERUS. 


57 


(2.)  By  the  bimanual  examination  of  the  pelvic  contents. — This  is  pro- 
bably the  best  method,  although  it  exaggerates  the  normal  anteversion 
of  the  uterus  in  a  way  that  will  be  readily  understood  when  the  chapter 
on  the  Bimanual  has  been  studied. 

(3).  By  the  use  of  the  sound,  or  by  a  more  elaborate  means  described 
by  Schultze.  Space  does  not  permit  of  a  full  description  of  the  latter, 
but  a  good  account  of  it  is  given  in  Foster's  paper. 

THE      LOCAL     DIVISIONS     OF     THE      PELVIC-FLOOR     PERITONEUM     AS     VIEWED 
THROUGH  THE  PELVIC  BRIM,  AND  THE  POSITION  OF  THE  UTERINE  ANNEXA. 

For  valuable  papers  and  sections  on  this  subject,  we  are  indebted  to 
Hasse  of  Breslau,  Ruedinger  of  Munich,  and  His  of  Leipzig  (fig.  50  and 
Plate  V.).  Hasse  froze  not  quite  thoroughly  a  female  cadaver  in  the 
upright  posture,  cut  through  the  abdomen  transversely,  and  then  lifted 
out  the  softened  viscera  until  the  pelvic  contents  were  exposed  undis- 
turbed. The  bladder  was  moderately  distended. 


,  the  Brim. 


FIG.  51. 

POSITION  of  FUSDCS  UTERI  and  lie  of  OVAEIES.     Bladder  distended  (Schultze). 

Fig.  50  shows  Hasse's  drawing.  The  fundus  of  the  uterus  lying  Pelvic 
on  the  bladder  is  well  seen.  In  front  of  the  broad  ligament — of  which  ^seen 
the  infundibulo-pelvic  ligament  is  the  only  portion  visible  in  fig.  50 — through 
we  have,  on  each  side,  the  paravesical  pouch  of  the  peritoneum.  Behind 
it,  lies  the  lateral  pouch  of  Douglas;  while  just  behind  the  uterus  and 
bounded  on  each  side  by  the  utero-sacral  ligament  is  the  pouch  of 
Douglas  proper.  The  Fallopian  tubes  lie  in  the  true  pelvis,  in  the 
paravesical  pouch.  Each  broad  ligament  sweeps  outwards  and  backwards 
to  near  the  sacro-iliac  synchondrosis  of  its  own  side.  The  position  of 
the  ureter  is  well  indicated. 


58 


ANATOMY  OF  PELVIS. 


l>inrtic.n 
of  OvarieB. 


According  to  Hasse  the  long  axis  of  each  ovary  runs  outwards  and 
forwards,  forming  with  the  transverse  axis  of  the  uterus  an  angle  open 
to  the  front.  Part  of  each  ovary  (the  half)  projects  above  the  plane  of 
the  pelvic  brim.  Schultze  figures  the  ovaries  as  having  their  long  axes 
almost  antero-posterior  (fig.  51),  and  His  in  his  cases  found  the  long  axes 
nearly  vertical.  In  recent  sections,  the  authors  found  the  ovary  lying 
nearly  vertical  as  His  describes  (v.  PI.  I.).  The  long  axis  of  the  ovary  on 
the  side  to  which  the  uterus  is  displaced  is  nearly  vertical,  while  the  ovary 
of  that  side  from  which  the  uterus  is  displaced  is  more  transverse  (v.  page 
22,  and  PI.  I.,  fig.  2). 

r> 


FIG.  52 

TTERUH.    A  with  bladder  and  rectum  empty;  B,  C,  D  according  to  distention  of  bladder 
(V anile  Wark-er). 

THE   PHYSIOLOGICAL   CHANGES    IN    THE    POSITION    OF    THE    UTERUS. 

The  mobility  of  the  uterus  is  one  of  its  most  characteristic  features. 
'ery  movement  of  respiration,  in  singing,  in  walking,  and  in 


1'l.ATU   IV. 


SURFACE-VIEW  OF  ABDOMEN  AND  THORAX  ;    THE  SECTION  IS  SEEN   AT 
PLATE  V. 


1.  Right  Hyi>ochon(iriac. 
4.  Right  Lumbar. 
7.  Right  Iliac. 


2.  Epigastric. 
:..  rmbilicul. 
8.  Hypogastric. 


3.  Left  Hypochondriac. 
(5.  Left  Lumbar. 
9.  Left  Iliae. 


Hit  jin.<itlnnof  the  Diaphragm. 


PLATE  V. 


PLATE  V.— CORONAL  SECTION  OP  FROZEN   FEMALE  CADAVER 

(RUEDINGER). 


POSITION  OF   UTERUS.  59' 

all  violent  movements,  the  uterine  position  is  changed.  Van  de 
Warker  has  studied,  in  a  valuable  paper,  the  influences  bringing  about 
these  changes  in  position ;  this  may  be  consulted  for  details  of  his 
method  of  investigation  and  results  obtained. 

Of  the  greatest  importance  is  the  effect  of  the  distended  bladder  on  Effect  of 
the  uterine  position.     As  the  bladder  fills,  the  uterus  becomes  retroposed  ona 
to  an  extent  shown  at  figs.  48,  51,  and  52.     The  intestines  are  forced  out  of  Uterus 
of  the  upper  part  of  Douglas'  pouch,  and  the  height  of  the  peritoneal 
reflection  from  the  anterior  abdominal  wall  is  considerably  increased. 
All  these  points  are  well  illustrated  by  fig.  42  from  Pirogoff.     As  the 
urine  is  evacuated,  the  uterus  passes  forward  to  its  normal  anteverted 
condition  and  the  intestines  pass  back  into  Douglas'  pouch.     Probably, 
undue  distention  of  the  bladder  leads  to  permanent  retroversion  in  some 
cases,  especially  if  the  uterus  be  gravid.     Kectal  distention  displaces  the 
uterus  forwards  and  to  the  right  side. 


THE    RELATION    OF    THE    SMALL    INTESTINE    TO    THE    PELVIC    FLOOR 
AND    TO    THE    UTERUS    WITH    ITS    ANNEXA. 

The  small  intestine  lies  resting  on  the  uterus,  ovaries,  Fallopian  tubes,  Relation 

and  broad  ligaments.     There  is  usually  no  small  intestine  in  the  vesico-° f  small 

*  _  •  Intestines 

uterine  pouch.  When  the  bladder  is  empty  and  the  unimpregnated  iiterus  to  Uterus. 
to  the  front,  there  is  small  intestine  in  Douglas'  pouch  except  at  its  very 
lowest  part.  The  pouch  of  Douglas  becomes  emptied  of  intestine  as  the 
bladder  distends,  aud  has  no  intestine  in  it  when  the  uterus  is  retro- 
verted.  Many  authors  assert  that  there  is  never  small  intestine  in 
Douglas'  pouch.  This  opinion  is  undoubtedly  wrong,  as  any  one  can 
satisfy  himself  by  studying  sections.  Often  Douglas'  pouch  contains 
serum,  and  this  displaces  the  intestine.  Figures  36,  42,  50,  bear  out 
these  opinions  ;  fig.  45  and  Plate  V.  should  be  carefully  studied  as  illus- 
trating the  position  of  the  superjacent  intestines.  The  paravesical 
pouch  probably  contains  intestine  when  the  uterus  lies  to  the  front,  and 
certainly  contains  it  when  the  uterus  is  pathologically  retroverted. 
Occasionally,  the  omentum  may  interpose  between  the  small  intestine 
and  the  pelvic  viscera. 

To  sum  up  briefly  : — 

a.  The  uterus  and  bladder  behave  practically  as  one  organ  qud  position  Summary 
(i.e.,  they  move  together),  when  the  uterus  is  to  the  front.  as  *?. 

'      T       mi  position 

6.  The  exact  angle  which  the  uterus  makes  with  the  horizon  cannot  of  Uterus, 
be  fixed,  and  knowledge  on  this  point  is  not  necessary. 

c.  The  uterus  lies  normally  to  the  front,  but  has  a  range  of  mobility 
indicated  in  fig.  52.  The  posterior  lip  of  the  cervix  is  '6  to  1*2  in. 
(1'5  to  3  cm.)  above  the  tip  of  the  coccyx.  By  digital  pressure  the 
uterus  can  be  elevated  about  1|-  in.  (4  cm.). 


CHAPTER   IV. 

THE  STRUCTURAL,  ANATOMY  OF   THE   FEMALE   PELVIC 
FLOOR:   THE  PELVIC-FLOOR  PROJECTION. 

LITERA  TVRE. 

STRUCTURAL  ANATOMY.  Hart — The  Structural  Anatomy  of  the  Female  Pelvic  Floor : 
Edinburgh,  1881.  Atlas  of  Female  Pelvic  Anatomy  :  1884.  Supplement  to  ditto  : 
1885.  "VV.  &  A.  K.  Johnston,  Edinburgh  and  London.  Symington — A  Contribution 
to  the  Normal  Anatomy  of  the  Female  Pelvic  Floor  :  Edin.  Med.  Jour. ,  March,  1889. 

PELVIC-FLOOR  PROJECTION.  Foster — Topographical  Anatomy  of  Uterus,  etc.  :  Am.  J. 
of  Obst.,  XIII.,  p.  30.  Schrceder — Noch  ein  Wort  iiber  die  nor  male  Lage  und  die 
Lageveranderungen  der  Gebarmutter  :  Arch.  f.  Gynak.,  Bd.  IX.,  S.  68.  Schultze — 
Zur  Kenntniss  von  der  Lage  der  Eingeweide  im  weiblichen  Becken  :  Archiv  f.  Gyn., 
Bd.  IX.,  S.  262.  Simpson  and  Hart — The  Relation  of  the  Abdominal  and  Pelvic 
Organs  in  the  Female  :  W.  &  A.  K.  Johnston,  Edinburgh  and  London,  1881. 

THE  STRUCTURAL  ANATOMY   OF   THE  FEMALE    PELVIC 

FLOOR. 

HITHERTO  we  have  regarded  the  pelvic  floor  in  detail  as  made  up  of 

bladder,  vaginal  walls,  rectum,  connective  tissue,  and  peritoneum.     Tn 

this  chapter  we  purpose  considering  it  in  its  structural  aspect.     In  its 

formation,  the  following  functions  have  been  provided  for.     As  compared 

Structure   with  the  floor  of  the  male  pelvis,  the  female  pelvic  floor  differs  in  having 

Floor  with  m  ^  tne  c^eft  known  as  the  vagina.     Then   further,  women  have  to 

regard  to    undergo  parturition  in  which  the  child   is  born  throug;h  the   vagina, 
function.        ,  .  ,     . 

which  is  then  greatly   distended.     At   the    same  time   a  woman   has 

resting  on  her  pelvic  floor  the  same  abdominal  viscera  as  the  male, 
and  her  pelvic  floor  is  also  subjected  to  the  same  strain  from  intra- 
abdominal  pressure.  Thus  we  have  to  explain  how  the  female  pelvic 
floor  has  been  constructed  so  as  to  allow  of  parturition  and  the  rectal 
and  vesical  functions  and  yet  remain  strong  enough  to  resist  ordinary 
intra-abdominal  pressure.  The  question  is  a  structural  or  architectural 
one.  We  study  it  in  this  present  chapter  just  as  we  should  study  the 
structure  of  a  box  or  chair. 

In  order  to  understand  this  question,  we  must  study  the  pelvic  floor 
as  seen  both  in  sagittal  mesial  and  in  axial  coronal  section. 

a.  Sagittal  Mesial  Section. 
Its  appear-       T     ,,.       . 

•  (cf.  PL  I.)  we  see  the  pelvic  floor  or  diaphragm  stretch- 

SdSr1      ing  from  symphysis  pubis  to  sacrum.     The  anus  is  to  be  imagined  closed 
Section,     as  in  life.     The  first  thing  to  note  is  the  vagina,  which  is  seen  as  a 


STRUCTURAL   ANATOMY.  61 

cleft  running  upwards  in  the  pelvic  floor  from  hymen  to  cervix  uteri. 
Its  walls  are  in  close  apposition  (vide  figs,  passim}.  They  are  often 
erroneously  represented  apart ;  in  order,  as  it  were,  to  let  the  student 
see  the  vagina.  This  is  wrong,  however.  It  is  no  more  necessary  to 
figure  the  vaginal  walls  always  apart,  than  it  would  be  always  to  sketch 
a  man  with  his  mouth  open  to  render  it  visible.  The  first  idea  one  gets 
on  looking  at  a  frozen  section  is  that,  owing  to  the  apposition  of  the 
vaginal  walls,  the  pelvic-floor  is  unbroken ;  and  that  the  vaginal  cleft, 
the  introduction  of  which  does  weaken  the  floor  somewhat,  cuts  it  not 
perpendicularly  to  the  horizon  but  obliquely  at  an  angle  of  about  60°. 

The  pelvic  floor,  as  seen  in  this  section,  is  made  up  of  two  segments 
Avhich  are  known  as  the  pubic  and  sacral  segments.  It  is  of  importance 
to  define  these  exactly. 

The  Pubic  Segment  is  made  up  of  loose  tissue,  viz.,  bladder,  urethra,  The  Pubic 
anterior  vaginal  wall,  and  bladder-peritoneum.  It  is  attached  in  front  egmen  • 
to  the  symphysis  pubis.  This  attachment  is  a  loose  one ;  the  bladder 
and  urethra,  meeting  one  another  at  right  angles,  are  separated  from  the 
pubes  by  the  pyramidal  deposit  of  loose  fat  already  described  as  the 
retropubic  fat  deposit.  Note  specially  that  the  retropubic  fat  deposit 
as  seen  in  this  section — that  of  a  subject  in  the  dorsal  or  the  erect 
posture — is  triangular ;  and  that  the  peritoneum  passes  from  the  anterior 
abdominal  wall  on  to  the  fundus  of  the  bladder,  just  a  little  above  the 
top  of  the  symphysis.  Below  the  pubic  arch,  the  urethra  becomes 
blended  with  the  perineal  muscles  there. 

The  Sacral  Segment  is  attached  to  the  coccyx  and  sacrum  ;  it  consists  The  Sacral 
of  rectum,  perineum,  posterior  vaginal  wall,  and  strong  tendinous  and     gmen  ' 
muscular  tissue.     The  inferior  portion  of  this  segment,  the  perineum, 
lies  about  1|  inches  from  the  symphysis. 

In  addition  to  the  retropubic  fat  deposit,  it  should  be  noted  that — 

a.  The  posterior  wall  of  the  bladder   is   loosely   attached  to  the 
anterior  vaginal  wall ; 

b.  The  urethra  and  anterior  vaginal  wall  are  closely  blended ; 

c.  The  posterior  vaginal  wall  and  anterior  rectal  wall  are  loosely 
connected,   as    far   down   as    the   apex  of  the    perineal    body 
(fig.  33). 

The   two   segments,    as   seen   in   sagittal   mesial    section,    are   thus  The  Seg- 
anatomically  contrasted :— 

The  pubic  segment  is  made  up  of  loose  tissue,  and  is  loosely  attacked 
to  the  pubic  symphysis;  the  sacral  segment  is  made  up  of  dense  tissue 
and  is  firmly  dovetailed  into  the  sacrum  and  coccyx. 

They  are  further  contrasted  functionally  : — 

The  pubic  segment  is  drawn  up  during  labour;  the  sacral  segment  is 
driven  down. 

The  proof  of  this  functional  contrast  is  too  elaborate  to  be  given 


62 


ANATOMY  OF  PZLVIS. 


here,  but  will  be  found  in  detail  in  Hart's  Atlas.  Briefly  stated  it 
is  that  during  labour  the  pubic  and  sacral  segments  as  seen  in  a  sagittal 
mesial  section  may  be  likened  to  two  folding  doors.  Uterine  action 
pulls  up  the  pubic  segment,  and  drives  the  child  down  against  the  sacral 
one.  This  action  is  analogous  to  the  way  one  passes  out  through  two 
folding  doors,  when  he  pulls  the  one  door  towards  him  and  pushes  the 


FIG.  53. 


^ 

other  from  him      As  the  result  of  this  elevation  of  the  pubic  segment, 
the  bladder  r   drawn  above  the  pubes  and  its  peritoneum  stripped  off 


STRUCTURAL   ANATOMY.  63 

The  various  components  of  the  pubic  segment  are  definitely  displaced  Displace- 

•     -x  TU      *v  i  •    e  *.  •  ment  of 

in  its  movements.      I hus  the  retropubic  iat  is —  the  Pubic 

1 .  Behind  the  pubes  in  the  nonparturient  female  (fig.  49)  ;  Segment. 

2.  Above  it  in  the  parturient  female  (fig.  53)  ; 

3.  Below  it  in  prolapsus  uteri ; 

4.  Below  it  in  the  extra  pelvic-floor  projection  of  pregnancy  ; 

5.  Partially  above  the  symphysis  in  the  genupectoral  posture  (fig.  60). 
The  peritoneum  is — 

1.  Reflected   on   to   the   top   of  the  empty   bladder  in  the  non- 

parturient  female ; 

2.  Stripped  off"  the  bladder  during  parturition  ; 

3.  Reflected  on  to  fundus  of  empty  bladder,  at  a  higher  level  above 

symphysis,  in  the  genupectoral  posture. 

Thus  the  peritoneum  over  the  bladder  is  movable;  the  peritoneum  over 
the  sacral  segment  is  fixed. 

b.  Axial  Coronal  Section. 

If  now  we  study  axial  coronal  sections,  we  shall  find  these  views  Axial 
(based  on  sagittal  mesial)  both  enlarged  and  modified.  If  actual  sections  Section, 
such  as  are  shewn  in  PI.  III.,  figs.  1  and  2,  be  examined  it  will  be 
found  that,  owing  to  the  presence  of  loose  tissue,  a  line  of  cleavage  runs 
within  the  obturator  internus,  upper  part  of  the  levator  ani,  and  rectum, 
separating  these  structures  from  the  vagina.  We  thus  find  a  complete 
ring  of  loose  tissue  of  which  part  has  been  seen  in  sagittal  mesial  section 
and  part  in  axial  coronal  section.  This  ring  of  loose  tissue  runs  as 
follows  : — beginning  behind  the  pubes  (retropubic  fat),  it  passes  on  the 
internal  aspect  of  the  obturator  internus  and  upper  portion  of  Levator 
ani  of  the  left  side ;  between  the  posterior  vaginal  and  anterior  rectal 
walls  ;  on  the  inner  aspect  of  the  obturator  internus  and  upper  portion 
of  the  Levator  ani  of  the  right  side  ;  and  then  back  to  the  retropubic  fat. 
This  ring  of  loose  tissue  divides  the  pelvic  floor  into  two  portions : — 

a.  The  entire  displaceable  portion  ; 

b.  The  entire  fixed  portion. 

a.  The   entire   displaceable  portion   comprises   bladder,    urethra,   and 
vaginal   walls.     It   has   resting  upon  it  the  uterus,  broad  ligaments, 
Fallopian  tubes,  and  ovaries  ;  and  lies  within  the  ring  of  loose  tissue. 

b.  The  entire  fixed  portion  lies  outside  of  the  ring  of  loose  tissue.     If 
the  entire  displaceable  portion  were  cut  out  of  the  pelvic  floor,  then  on 
looking  through  the  pelvic  brim,  we  should  see,  in  front,  the  posterior 
aspect  of  the  pubes,  sloping  downwards  and  backwards ;  at  the  sides,  the 
inner  aspects  of  the  obturator  internus  sloping  downwards  and  inwards ; 
and  behind,  the  anterior  rectal  wall  and  sacrum  sloping  downwards  and 


64 


ANATOMY  OF  PELVIS. 


Divisions 
of  Pelvic 
Floor. 


forwards.  We  should,  in  fact,  be  looking  down  into  a  funnel  whose 
walls  all  sloped  towards  a  central  point.  This  funnel  forms  the  entire 
fixed  portion  of  the  pelvic  floor. 

It  will  now  be  understood  that  the  entire  fixed  portion  supports  the 
entire  displaceable  portion ;  and  that  consequently  on  these  two  com- 
bined (i.e.,  the  whole  pelvic  floor)  the  uterus  and  annexa  and  the 
abdominal  viscera  rest. 

The  terminology  given  need  not  confuse  if  it  be  remembered  that  the 
terms  'pubic  segment  and  sacral  segment'  apply  to  sagittal  mesial  sec- 
tions only,  and  are  applicable  to  the  mechanism  of  parturition  ;  while 
'entire  displaceable  and  entire  fixed  portions'  apply  to  transverse 
sections,  and  are  to  be  used  for  the  general  physics  of  the  pelvic  floor 
and  for  prolapsus  uteri.  The  relation  between  the  two  views  given  by 
sagittal  mesial  section  and  by  transverse  (or  by  axial  coronal)  section 
may  be  represented  as  follows  : — 

Sagittal  Mesial  Section.  Transverse  or  Axial  Coronal  Section. 

(  Bladder  and  urethra, 
Pubic  Segment.    \   .         .  .     , 

I  Anterior  vaginal 

\  o 


Entire  displaceable 
portion. 

/•Posterior  vaginal  wall, 

Sacral  Segment.    J  Tissue  attached  to  sacrum, 
(Bowel  in  pelvic  floor, 
All  outside  of  inner  aspects 
of  levator  ani. 


Entire  fixed 
portion. 


Functions       The  chief  functions  demanded  of  the  female  pelvic  floor  are — 

of  Pelvic 

Floor.  a.   Support  of  Infra-abdominal  Pressure, 

b.  Vesical  and  rectal  functions, 

c.  Parturition. 

a.  Support  of  Intra-abdominal  Pressure.  The  abdominal  and  pelvic 
viscera  rest  on  the  pelvic  floor ;  more  correctly,  these  viscera  (along  with 
the  entire  displaceable  portion  of  the  pelvic  floor)  rest  on  the  entire 
fixed  portion  of  the  pelvic  floor,  the  inward  convergence  of  whose  parts 
enables  them  to  support  these.  Prolapsus  uteri  is  thus,  as  we  shall 
afterwards  see,  not  a  mere  uterine  descent,  but  a  downward  displace- 
ment of  the  abdominal  and  pelvic  viscera  along  with  the  entire  dis- 
placeable portion  of  the  pelvic  floor. 

6.  Vesical  and  rectal  functions.  The  loose  tissue  round  the  rectum 
and  bladder  allows  of  the  contraction  and  diminution  in  bulk  of  these 
organs  which  are  necessary  for  the  expulsion  of  their  contents. 

c.  Parturition.     This  is  the  great  function  of  the  pelvic  floor,  and  is  pro- 


PELVIC-FLOOR   PROJECTION.  65 

vided  for  structurally  as  follows.  The  child  is  driven  through  the  vagina 
(i.e.  through  the  entire  displaceable  portion)  by  the  upward  tension  of 
the  uterine  muscle  attached  to  the  top  of  the  vaginal  walls  and  by  the 
dilating  pressure  of  the  foetal  head.  This  upward  movement  of  the 
entire  displaceable  segment  is  allowed  by  the  ring  of  loose  tissue  of 
which  we  have  spoken.  We  are  now  able  to  understand  the  full  signifi- 
cance of  the  statement  already  made  that  the  pubic  segment  of  the 
pelvic  floor  is  pulled  up  partly  into  the  abdominal  cavity  while  the 
sacral  segment  is  driven  downwards  and  backwards.  In  addition,  the 
levatores  ani  will  be  pressed  outwards. 

The  result  of  parturition  is  (1)  To  dilate  the  vaginal  walls  and 
render  them  more  easily  everted,  (2)  to  tear  the  inferior  margin  of 
the  sacral  segment,  i.e.  the  perineum,  (3)  to  elongate  and  slacken  the 
ring  of  loose  tissiie  uniting  the  entire  displaceable  and  the  entire  fixed 
portions.  In  this  way,  it  favours  that  driving  downwards  and  outwards 
of  the  entire  displaceable  portion  which  happens  in  Prolapsus  uteri. 


PELVIC-FLOOR  PROJECTION. 

By  this  is  understood  the  amount  of  projection  of  the  pelvic  floor,  in  Definition 
sagittal  mesial  section,  beyond  the  straight  line  joining  the  tip  of  the^0^p^.Q, 
coccyx  and  the  subpubic  ligament — i.e.,  beyond  the  conjugate  of  outlet  (fig.  54).  jection. 


a 


FIG.  54. 

DIAGRAM  to  show  what  is  meant  by  PELVIC-FLOOR  PROJECTION,  a p  =  conjugate  of  outlet.  A  per- 
pendicular bisecting  a  p  and  cutting  the  arc  gives  the  greatest  pelvic-floor  projection 
(F.  P.  Foster). 


Definite  results  have  not  as  yet  been  obtained,  but  this  is  one  special 
reason  why  attention  should  be  directed  to  it. 

Schroeder  measured  the  conjugate  at  the  outlet  with  callipers ;  and 
then  passed  a  measuring  line  from  the  coccyx  to  the  apex  of  the  pubic 


66 


ANATOMY  OF  PELVIS. 


arch,  the  tape  following  the  curve  of  the  pelvic  floor. 
table  gives  some  of  his  results. 


The  subjoined 


Distance  from  tip  of  coccyx  to  lower 
border  of  symphysis. 


By  Tape  Measure. 

Average  of  the  pregnant  woman  cm.  1  |-35 

gynecological  patients     „     12'6 

"  IT  "1 3-9 

uulliparse  »     i6  * 


J>y  Callipers. 


9-15 
8-27 
9-75 


Mode  of 
measuring 
pelvic- 
poor  pro- 
jection. 


Schroeder's  deduction  is  that  the  average  projection  of  the  pelvic 
floor  beyond  the  plane  of  the  pelvic  outlet  is  4'1  cm.  There  is  no 
doubt  that  this  is  an  excessive  average. 

F.  P.  Foster  of  New  York  has  written  ably  on  this  subject,  and 
made  a  large  series  of  observations.  Fig.  55  shows  the  callipers  he 


FIG.  55. 

CALLIPERS  for  measuring  PELVIC-FLOOR  PROJECTION  (Foster). 

employed.  The  ends  of  the  limbs  (a  and  b)  are  placed  on  the  tip  of 
the  coccyx  and  lower  border  of  the  symphysis  pubis.  respectively. 
The  horizontal  bar  between  these  limbs  is  graduated  in  cm.,  and  the 
limb  (a)  glides  along  it  in  a  groove.  A  movable  upright  (c),  also  gradu- 
ated, has  its  upper  point  placed  against  the  most  projecting  part  of  the 
pelvic  floor.  If  now  the  whole  apparatus  be  removed  and  laid  flat  on  a 
sheet  of  paper,  the  conjugate  and  amount  of  projection  can  be  read  off 
at  once.  Greater  accuracy  is  ensured  by  noting,  before  removing  the 
apparatus,  the  point  on  the  transverse  bar  at  which  the  upright  (c) 
stands  as  well  as  the  reading  which  it  gives. 

Foster's  average  (2 '5  cm.)  of  the  pelvic-floor  projection  is  less  than 


PELVIC-FLOOR   PROJECTION. 


67 


Schroeder's.  He  placed  the  patient  semiprone,  however ;  a  position  in 
which  the  pelvic-floor  projection  is  slightly  diminished.  Fig.  56  shows 
Foster's  diagram  of  pelvic-floor  projection.  The  uterus  is  more  ante- 
verted  than  in  Foster's  original  drawing. 

Measurements  made  on  frozen  sections  must  be  used  with  caution. 
Schroeder  has  justified  his  average  by  such  measurements,  but  has  taken 
no  account  of  the  existence  of  pregnancy  in  some  of  the  cases. 


Summary 


FIG.  56. 

DIAGRAM  of  PELVIC-  FLOOR  PROJECTION  and  position  of  uterus,  modified  from  foster. 
The  anterior  and  posterior  walls  of  the  anus  are  not  in  apposition,  as  shown  in  the  diagram. 

We  might  tentatively  advance  the  following  statements  :  — 

(1.)  The  pelvic-floor  projection  is  over-estimated  by  Schroeder; 

(2.)  Foster's  average  is  nearer  the  mark  ; 

(3.)  The  retropubic  fat  gives  a  rough  index  of  the  position  of  thejection. 
pubic  segment  (figs.  39,  40,  47)  ; 

(4.)  The  pelvic-floor  projection  is  increased  by  advanced  and  even  by 
early  pregnancy  (Braune's  Plates). 

The  whole  inquiry  needs  further  investigation  in  order  to  settle  also 
other  points,  among  which  we  may  mention  the  relation  of  the  vagina  to 
the  pelvic  outlet  and  the  varying  amount  of  pelvic-floor  projection  in 
different  postures. 


CHAPTER  V. 

THE  BLOOD-VESSELS,  LYMPHATICS,  AND  NERVES  OF 
THE  PELVIS:  DEVELOPMENT  OF  PELVIC  ORGANS. 

LITERATURE. 

BLOOD-VESSELS.  Henle — Handbuch  der  Eingeweidelehre  des  Menschen  :  Braunschweig, 
1866.  Hyrtt— Die  Corrosions-anatomic  und  ihre  Ergebnisse  :  W.  Braumiiller,  "\Vieii, 
1873.  Klein  and  Smith's  Atlas.  Luschka — Die  Musculatur  am  Boden  des  weib- 
lichen  Beckens  :  Wien,  1861.  Quain— Anatomy,  8th  Ed.  :  London,  1882.  Sappey— 
Traite  d'Anatomie  Descriptive  :  Paris,  1873.  Savage— Female  Pelvic  Organs, 
5th  Ed.  :  London,  1882.  Tail,  Lawson — The  Pathology  and  Treatment  of  Diseases 
of  the  Ovary,  p.  8.  :  Birmingham,  1883.  J.  Williams — On  the  Circulation  in  the 
Uterus,  with  some  of  its  Anatomical  and  Pathological  Bearings  :  Obstet.  Soc.  of 
London,  1885. 

LYMPHATICS.  Bouryery  and  Jacob — Trait6  Complet  de  1'Anatomie  de  1'Homme  :  Paris, 
1839.  Championnttre — Lymphatiques  Uterines  et  Lymphangite  Uterine :  Bull, 
de  la  Soc.  Med.  des  Hdpitaux  de  Paris,  Vol.  VII.  Curnow — The  Lymphatic 
System  and  its  Diseases  :  Lancet,  1879.  Klein — The  Anatomy  of  the  Lymphatic 
System  :  London,  1873.  Le  Bee — Contributions  ;\  1'Etude  des  Ligaments  larges, 
etc. :  Gaz.  Heb.,  15  Avril  1881.  G.  Leopold — Die  Lymphgefasse  des  normalen  nicht 
schwangeren  Uterus :  Archiv  fur  Gynak.,  Bd.  VI.,  S.  1.  W.  T.  Lusk — Puerperal 
Fever  :  International  Congress  Tr.,  Philad.,  1877.  Sappey,  Savage — Op.  cit. 

NERVES.— T.  Snow  Beck— The  Nerves  of  the  Uterus  :  Phil.  Tr.,  1846.  Flower— Diagrams 
of  the  Nerves  of  the  Human  Body  :  J.  and  A.  Churchill,  London,  1872.  Franken- 
hdusei — Die  Nerven  Der  Gebarmutter  und  ihre  Endigung  in  den  glatten  Muskel- 
fasern :  Jena,  1867.  Jastrebow — On  the  normal  and  pathological  Anatomy  of  the 
ganglion  cervicale  uteri :  Lond.  Obstet.  Trans.,  1881.  R.  Lee — The  Anatomy  of 
the  Nerves  of  the  Uterus  :  London,  Bailli^re,  1841.  Tiedemann — Tabulze  Nervorum 
Uteri :  Heidelberg,  1822. 

DEVELOPMENT  OK  THE  PELVIC  ORGANS.  Foulis — The  Development  of  the  Ova,  and  the 
Structure  of  the  Ovary  in  Man  and  the  other  Mammalia  :  Tr.  E.  S.,  Edin.,  Vol. 
XXVII.  Klein  and  Smith,  Quain,  Turner — Op.  cit. 

BLOOD-VESSELS. 

Preliminary  Remarks: — The  blood  supply  to  the  pelvic  organs  and 
perineum  is  derived  from  the  ovarian  arteries  (which  are  branches  of  the 
abdominal  aorta),  and  from  the  uterine,  vaginal,  and  internal  pudic 
arteries  (which  are  all  branches  of  the  anterior  division  of  the  internal 
iliac). 

We  shall  first  consider  the  arterial  supply  of  the  uterus,  ovary,  Fal- 
lopian tubes,  vagina,  bladder,  rectum,  and  that  of  the  perineal  region ; 
and  then  the  venous  distribution. 

Arterial 

supply  to  ARTERIAL  SUPPLY. 

Uterus  and  ,,  ,     .         .    . 

<>•..„>.  (1.)  Arterial  supply  to  uterus,  ovary,  etc. — The  Ovarian  artery  of  each 


fl.ATK    VI  . 


BLOOD-VESSELS.  69 

side  (corresponding  to  the  spermatic  of  the  male)  is  a  branch  of  the 
abdominal  aorta.  Its  relations  when  in  the  abdomen  do  not  concern 
us  here.  In  the  pelvis  it  passes  between  the  layers  of  the  broad  liga- 
ment, running  tortuously  towards  the  upper  angle  of  the  uterus.  Near 
this  it  divides  into  two  branches.  The  upper  supplies  the  fundus  uteri ; 
the  lower  anastomoses  at  the  side  of  the  uterus  with  the  uterine  artery 
(Plate  VI.  c,  d). 

The  Ovarian  Artery  gives  off — 

Branches  to  the  ampulla  of  the  Fallopian  tube  (Plate  VI.  a'  a'), 

Branches  to  the  isthmus  (&'), 

Numerous  branches  to  the  ovary  (c'  c  c'), 

Branch  to  the  round  ligament  (6). 

The  Uterine  Artery  (Plate  VI.  e)  springs  from  the  anterior  division  of 
the  internal  iliac,  and  passes  downwards  and  inwards  towards  the  cervix 
uteri.  It  then  passes  upwards  between  the  layers  of  the  broad  ligament 
by  the  side  of  the  uterus,  in  an  exceedingly  tortuous  manner  well  shown 
in  Plate  VI.,  to  anastomose  with  the  lower  branch  of  the  ovarian.  The 
course  of  the  blood-vessels  in  the  uterine  wall  has  been  recently  studied 
and  described  by  J.  Williams  with  special  reference  to  some  ana- 
tomical and  pathological  points.  The  primary  branches  after  enter- 
ing the  uterine  tissue  have  a  somewhat  superficial  course,  being 
separated  from  the  peritoneum  by  only  a  thin  layer  of  muscular  fibres. 
From  these,  secondary  branches  run  towards  the  mucous  surface  in  a 
direction  perpendicular  to  that  surface  ;  these  anastomose  freely  and  end 
in  capillary  loops  in  the  mucous  membrane.  All  internal  to  the  primary 
branches — -the  greater  part  of  the  muscular  wall — .belongs,  according  to 
Williams,  to  the  mucous  membrane,  i.e.,  is  muscularis  mucosae.  The 
Vaginal  arteries  (g  g  g}  usually  spring  immediately  from  the  anterior 
division  of  the  internal  iliac  artery,  but  sometimes  arise  from  the  uterine 
or  middle  hsemorrhoidal.  A  special  branch  of  the  uterine  artery  to 
the  cervix  joins  with  its  fellow  at  the  isthmus  to  form  the  circular 
artery,  and  with  those  of  the  vagina  to  form  the  azygos  artery  of 
the  vagina  (h  Ji).  The  vaginal  arteries  of  one  side  anastomose  freely 
with  those  of  the  other.  Plate  VI.,  from  Hyrtl,  illustrates  beauti- 
fully the  free  anastomosis  of  branches  of  the  aorta  with  the  ovarian, 
uterine,  and  vaginal  arteries.  It  should  be  noted  that,  in  operation 
for  removal  of  the  uterus,  ligature  of  the  broad  ligament  controls  all 
haemorrhage. 

From  the  same  anterior  division  of  the  internal  iliac  proceeds  the 
blood  supply  to  the  bladder  and  rectum. 

Arterial  supply  to  the  perineal  region. — This  comes  from  the  internal  Arterial 
pudic.     The  superficial  perineal  branch  supplies  the  labia  •  the  artery 
to  the  bulb  supplies  the  bulbus  vaginae ;    the  terminal  branches  go 
to  the  clitoris. 


70 


ANATOMY  OF  PELVIS. 

VENOUS  SUPPLY. 


Veins  of 
Pelvis. 


The  venous  supply  of  the  pelvis  is  very  abundant,  and  exists  in  the 
form  of  numerous  plexuses  freely  communicating  with  one  another. 
The  veins  are  unprovided  with  valves ;  haemorrhage  from  a  wound  is 
therefore  often  exceedingly  profuse,  especially  during  pregnancy  when 
the  whole  pelvic  vascular  system  is  hypertrophied. 


II 


S  > 


tH      £> 

I* 


The  following  is  a  summary  of  the  main  facts  as  to  the  venous 
supply  of  the  female  pelvis. 

The   Vesical  plexus  lies  external  to  the  muscular  coat  of  the  bladder. 

J  Oamon^dalpbxtu  lies  below  the  mucous  membrane  of  the  lower 
part  of  the  rectum. 


LYMPHATICS.  71 

The  veins  of  the  labia  correspond  in  distribution  to  the  arteries,  and 
those  from  the  outermost  parts  drain  into  the  pudic  which  opens  into 
the  common  iliac  vein.  Large  veins  from  the  labia  ininora  open  into 
the  pars  intermedia  of  the  bulb. 

The  veins  from  the  glans  and  corpus  clitoridis  pass  into  the  dorsal 
vein  of  the  clitoris,  which  communicates  with  the  vesical  plexus. 
The  veins  of  the  bulb  pass  into  the  vaginal  plexus. 
The  Vaginal  plexuses — one  outside  the  muscular  coat  and  one  in  the 
submucous  tissue — are  most  abundant  at  the  lower  part  of  the  vagina, 
communicate   with  the   hsemorrhoidal   and  vesical  plexuses,  and  open 
into  the  internal  iliac  vein. 

The  Uterine  plexus  is  very  abundant,  as  is  well  shown  in  one  of 
Hyrtl's  plates ;  it  ultimately  opens  into  the  ovarian  veins  (fig.  62), 
which  pass  on  the  right  side  to  the  inferior  vena  cava,  on  the  left  to 
the  left  renal  vein.  The  right  ovarian  vein  has  a  vah-e  where  it  pierces 
the  coat  of  the  inferior  vena  cava  (Brinton,  quoted  by  Lawson  Tait). 
The  veins  are  small,  lie  in  the  outer  muscular  coat,  and  run  longi- 
tudinally ;  in  the  middle  layer  of  that  coat  they  open  into  large  sinuses 
(surrounded  by  circular  unstriped  muscle)  with  which  the  capillary 
vessels  communicate.  This  is  an  arrangement  like  that  in  the  corpus 
spongiosum  of  the  penis  (Klein). 

The  Ovarian  plexus,  otherwise  known  as  the  pampiniform  plexus,  lies 
between  the  folds  of  the  broad  ligament  and  communicates  with  the 
uterine  plexus  (fig.  57).  Some  apply  this  term  to  all  the  veins  in  the 
broad  ligament.  The  ovarian  plexus  opens  into  the  inferior  vena  cava. 
Just  at  the  hilum  of  the  ovary  lies  the  collection  of  veins  known  as  the 
bulb  of  the  ovary. 

Beneath  the  peritoneum  and  between  the  layers  of  the  broad  ligaments 
are  vast  venous  plexuses.  Knowledge  on  this  point  is  of  the  highest 
importance  in  relation  to  pelvic  hsematocele. 

The  vesical,  hsemorrhoidal,  and  vaginal  plexuses,  with  the  pudic  veins, 
open  into  the  internal  iliac  vein  which  joins  the  inferior  vena  cava. 

From  the  hsemorrhoidal  plexus,  the  superior  hsemorrhoidal  vein  passes 
into  the  portal  system;  and  thus  we  get  a  communication  between  the 
pelvic  and  portal  venous  systems. 

In  the  vaginal  mucous  membrane,  clitoris  and  uterus,  we  have  erectile 
tissue,  i.e.,  veins  in  connective  tissue  with  unstriped  muscular  fibre. 

LYMPHATICS. 
Under  this  we  take  up — 

a.  The  Lymphatic  glands  ; 

b.  The  Lymphatic  Vessels. 

a.  The  Lymphatic  Glands. — These  are  (1.)  the  inguinal  glands,  which  o 


72  ANATOMY  OF  PELVIS. 

lie  parallel  to  and  just  below  Poupart's  ligament ;  and  (2.)  the  pelvic 
gland*.     These  latter  consist  of  the  following : — 

(a)  A  gland  at  the  isthmus  uteri  (C/tampionniere) ; 

(b)  Hypogastric    glands,  which    lie    subperitoneally  in  the    space 

between  the  external  and  internal  iliac  vessels ; 

(c)  Sacral,  on  the  lateral  aspect  of  the  anterior  surface  of  the  sacrum 

and  in  the  mesorectum;  and 

(d)  A  gland  or  collection  of  small  glands  at  the  obturator  foramen — 

the  obturator  gland  of  Guerin. 

These  all  pour  into  the  lumbar  glands,  which  lie  in  front  of  the  lumbar 
vertebrae  and  discharge  into  the  thoracic  duct. 

Lymphatic      b.   The   Lymphatic    Vessels.       (1.)  Of  External    Genitals. — Numerous 

External  vessels  f°rm  a  network  on  the  internal  aspect  of  the  labia  majora,  over 

Genitals,    the  labia  minora,  and  round  the  vaginal  and  urethral  orifices,  vestibule, 

and   clitoris ;  all  of  these  open  into  the  inguinal  glands.      From  this 

arrangement,  the  enlargement  of  the  inguinal  glands  in  syphilis  and 

vulvar  cancer  is  intelligible.     The  lymphatics  of  the  lower  fourth  of  the 

vagina  also  open  into  these  glands. 

Of  Vagina,  (2.)  Of  Vagina  (upper  three-fourths)  and  Cervix  Uteri — These  lym- 
phatics open  into  the  hypogastric  glands. 

So  far  we  have  followed  Sappey's  description.  Le  Bee,  however, 
asserts  that  the  lymphatics  of  the  vagina  pour  into  a  series  of  trunks  at 
the  level  of  the  isthmus  uteri,  and  that  those  of  the  cervix  join  them ; 
and  that  the  conjoined  lymphatics  then  pass  below  the  base  of  the  broad 
ligament  to  the  obturator  gland,  from  which  vessels  communicate  with 
others  from  the  thigh  and  even  from  the  epigastrium. 

The  relation  between  lymphatics  and  glands  is  as  follows  : — - 

(a)  Those  of  the  external  genitals  pass  into  the  inguinal  glands ; 

(6)  The  lymphatics  of  the  bladder,  vagina,  and  cervix  pass  to  the 
hypogastric  glands  (Sappey).  According  to  Le  Bee,  they  pass  to  the 
obturator  gland. 

Of  Uterus.  (3.)  Of  Uterus.— The  lymphatics  of  the  body  of  the  uterus  pass 
through  the  broad  ligaments ;  and,  along  with  those  from  the  ovary  and 
Fallopian  tube,  enter  the  lumbar  glands.  If  Le  Bee  be  right,  the  lym- 
phatics from  the  cervix  pass  below  the  broad  ligament  and  those  from 
the  uterus  along  the  upper  part  of  the  same.  Some  of  the  uterine  lym- 
phatics pass  along  the  round  ligament  to  the  groin. 

Leopold,  who  has  investigated  the  lymphatics  in  the  unimpregnated 
uterus,  considers  "  the  mucous  membrane  of  the  uterus  as  a  lymphatic 
surface  which  contains  no  special  lymphatic  vessels,  but  consists  of 
lymph  sinuses  covered  with  endothelium. 

The  lymph   passes   from   the    lymphatic    spaces   of  the   mucous 
membrane,  through  the   mucous  membrane   hollows,  into  the   lymph 


NERVES.  73 

spaces  and  vessels  of  the  muscular  coat,  surrounds  here  all  the  bundles 
up  to  the  serous  covering,  and  flows  into  the  larger  vessels  which 
enter  the  broad  ligament  in  the  neighbourhood  of  the  blood-vessels" 
(loc.  cit.,  S.  31). 

These  are  matters  not  of  mere  anatomical  detail,  but  of  the  very  highest 
pathological  and  practical  importance.  The  richness  of  blood  and  lym- 
phatic supply  to  the  vagina,  cervix,  and  uterus  explains  the  extraordinary 
rapidity  with  which  septic  matter  spreads  through  the  body,  and  the 
extreme  danger  which  may  attend  even  an  insignificant  lesion  of  the 
internal  genital  organs,  when  septic  matter  is  present  and  is  absorbed. 
We  may  remark  here  that  septic  matter  will  of  course  follow  the  lym- 
phatic routes  already  laid  down,  and  that  bacteria  can  penetrate  the  walls 
of  blood-vessels  and  pass  into  the  general  circulation.  It  should  not  be 
forgotten,  however,  that  the  bacteria  passing  along  the  lymphatic  vessels 
may  penetrate  them,  pass  into  the  peritoneal  cavity,  and  thence  spread 
through  the  diaphragm  to  set  up  the  pleurisy  and  pericarditis  so  common 
in  septicsemia  (Lusk).  Thorough  comprehension  of  lymphatic  distribu- 
tion and  knowledge  of  the  evil  effects  of  septic  matter  are  of  the  first 
importance  to  the  student. 

The  lymphatics  of  the  Rectum  lie  in  two  layers  (mucous  and  muscular), 
and  open  into  the  glands  of  the  mesorectum  or  into  the  sacral  glands. 

The  stomata  of  the  peritoneum  of  the  pelvis  communicate  with  lymph 
capillaries  lying  in  the  subendothelial  tissue.  Relation 

The    Inguinal    Glands  (parallel  to  Poupart's   ligament)    receive    the^mls" 
lymphatics  of  the  vulva,  lower  Jth  of  vagina,  and  urethra.  and  Lym- 

The  Hypogastric  or  Internal  Iliac  receive  those  of  the  bladder,  upper 
f  ths  of  vagina,  and  neck  of  uterus. 

The  Sacral  Glands  receive  those  from  the  rectum. 

The  Lumbar  Glands  receive  the  lymphatics  from  the  pelvic  glands, 
body  of  the  uterus,  Fallopian  tubes,  and  ovaries. 

NERVES. 

These  are  (a)  Spinal ;  (b)  Sympathetic. 

(a)  Spinal.     The  pelvic  muscles  are  supplied  as  follows  : — Levator  and  Pelvic 
Sphincter  ani  by  inferior  hsemorrhoidal  branch  of  pudic,  4th  and  5th 
sacral,  and  coccygeal  nerves ;    Coccygeiis,  by  4th    and  5th   sacral  and 
coccygeal  nerves ;  Muscles  of  Perineum  and  Clitoris,  by  the  branches  of 
pudic  nerve. 

(I)  Sympathetic.  The  hypogastric  plexus  lies  between  the  common 
iliac  arteries  ;  it  gives  off  branches  which,  reinforced  by  branches  from 
the  lumbar  and  sacral  ganglia  and  sacral  nerves,  form  the  inferior  hypo- 
gastric  plexuses — one  on  each  side  of  the  vagina.  From  these,  filaments 
proceed  to  the  vagina,  uterus,  Fallopian  tube,  and  ovary. 

Frankenhauser  describes  a  ganglion  at  the  cervix  uteri  and  also  a 


74  ANATOMY  OF  PELVIS. 

vesical  one.     Jastrebow  found  the  cervical  ganglion  to  be  a  plexus  with 
a  ganglion  enclosed  in  it. 

The  terminations  of  the  nerves  in  the  muscular  layers  of  the  uterus 
have  been  studied  by  Frankenhauser,  who  figures  them  passing  to  the 
nuclei  of  the  unstriped  muscle.  Those  entering  the  mucous  membrane 
are  said  to  end  in  ganglia.  Numerous  end  bulbs  have  been  found  in 
the  clitoris  and  vagina. 

DEVELOPMENT   OF   PELVIC   ORGANS. 

The  following  is  a  very  brief  summary  : — 

Develop-  The  Wolffian  bodies  appear  in  the  foetus  about  the  third  and  fourth 
week.  They  fulfil  the  function  of  kidneys  until  the  second  month,  and 
then  wither,  leaving  traces  in  the  presence  of  parovarium  and  Gartner's 
canal. 

The  Fallopian  tubes,  uterus,  and  vagina  arise  from  the  ducts  of 
Miiller.  These  appear  on  the  anterior  aspect  of  the  Wolffian  bodies; 
coalesce  below  to  form  the  uterus  and  vagina ;  while,  above,  they 
remain  separate,  as  the  Fallopian  tubes,  and  leave  traces  in  the  hydatid 
of  Morgagni. 

The  ovary  first  appears  as  a  thickening  on  the  Wolffian  bodies.  It 
is  made  up  of  interstitial  tissue  projecting  from  them  and  covered 
by  epithelium — the  germ  epithelium.  According  to  Foulis,  the  ova  are 
developed  from  the  latter ;  the  cells  of  the  membrana  granulosa  are 
formed  from  the  connective-tissue  corpuscles  of  the  interstitial,  tissue. 
Waldeyer  believes  that  the  ova  and  the  cells  of  the  membrana  granulosa 
both  originate  from  the  germ  epithelium ;  and  in  this  Balfour  agrees 
with  him  (vide  PI.  X.,  fig.  F). 

The  parovarium  arises  as  a  small  distinct  structure  at  the  summit  of 
each  Wolffian  body.  It  persists  in  the  female  (fig.  20).  In  the  male 
it  forms  the  epididymis. 

The  clitoris  is  developed  from  a  small  eminence  at  the  foot  of  the 
urogenital  sinus. 

Up  to  the  second  month  of  fetal  life  the  genital,  urinary,  and  intestinal 
ducts  open  into  the  cloaca ;  this  then  becomes  divided  by  a  transverse 
partition  into  a  posterior  anal,  and  anterior  urogenital  sinus.  The  vesti- 
bule in  the  adult  female  is  simply  the  lower  part  of  the  latter  sinus. 

The  labia  minora  result  from  the  non-coalescence  of  folds  analogous 
to  those  which,  by  their  coalescence,  form  in  the  male  the  corpus 
spongiosum  urethree. 

The  labia  majora  are  two  folds  which  remain  separate  in  the  female 
but  coalesce  in  the  male  to  form  the  scrotum. 

The  two  bulbi  vagina  are  homologous  to  the  corpus  spongiosum 
urethra. 

For  fuller  details,  see  Turner  and  Quain. 


CHAPTER    VI. 

PHYSICS  OF  THE  ABDOMEN  AND  PELVIS,  WITH  SPECIAL 
REFERENCE  TO  THE  SEMIPRONE  AND  GENUPECTORAL 
POSTURES. 

LITERA  TURE. 

W.  Braune — Die  Oberschenkelvene  des  Menschen  in  anatomischer  und  klinischer  Bezie- 
liung  :  Leipzig,  Veit  and  Co.,  1871.  J.  M.  Duncan — On  the  Retentive  Power  of  the 
Abdomen  :  Researches  in  Obstetrics,  p.  409.  Hart — The  Structural  Anatomy  of  the 
Female  Pelvic  Floor.  Schatz — Beitrage  zur  physiologischen  Geburtskunde  :  Archiv 
fur  Gynak.,  Bd.  IV.,  S.  191.  Einfluss  der  Lehre  vom  intraabdominaleii  Drucke 
auf  die  Gynakologie  :  Archiv  fiir  Gynak.,  Bd.  V.,  S.  227.  Simpson  and  Hart — The 
Relations  of  the  Abdominal  and  Pelvic  Organs  in  the  Female.  Van  de  Warkei — 
A  Study  of  the  Normal  Movements  of  the  Unimpregnated  Uterus :  N.  Y.  Med. 
Jour.,  Vol.  XXI.,  p.  337. 

IN  this  chapter  it  is  proposed  to  give  a  brief  sketch  of  a  subject  of  the 
highest  importance  but  still  in  its  infancy.  The  resume  must  be  re- 
stricted, from  want  of  space,  to  certain  practical  points  of  which  we 
consider  here  the  following  : — 

1.  The  effect  of  intra-abdominal  pressure  on  the  female  pelvic  floor  ; 

2.  The  results  brought  about  by  change  of  posture,   especially  by  the 
f/enupectoral  posture  ; 

3.  The   effect  on   uterine  position   of  digital  pressure  in   the   vaginal 
fornices. 

THE  EFFECT  OF  INTRA-ABDOMINAL   PRESSURE    ON    THE  FEMALE  PELVIC  FLOOR. 

We  suppose  the  body  to  be  in  the  upright  posture.     For  simplicity,  Effect  of 
the  pelvic  floor  is  considered  as  being  under  fluid  pressure.     Fig.  58^*^^- 
shows  the  effect  of  this  on  the  pelvic-floor  segments.     Fluid  pressure  pressure, 
acts  at  right  angles  to  the  limiting  surface,  which  in  this  case  is  the 
pelvic  peritoneum.     Thus,  if  the  perpendiculars  be  counted,  starting  from 
the  symphysis,  it  can  readily  be  seen  that  the  first  three  will  press  the 
pubic  segment  against  the  symphysis ;  that  the  fourth  and  fifth  will  do 
this  also,  biit  will  further  have  a  resultant  tending  to  drive  the  pubic 
past  the  sacral  segment ;  that  the  sixth  and  seventh  will,  directly,  tend  to 
do  this  last ;  and  that  the  others  will  drive  it  partly  past  the  sacral  seg- 
ment, and  partly  against  it.     From  want  of  rigidity  in  the  pubic  segment, 
this  driving-down  tendency  is  partly  lost.     Thus  the  effect  of  ordinary 
intra-abdominal  pressure  is  to  press  the  pubic  against  the  sacral  segment. 


76  ANATOMY  OF  PELVIS. 

Increased  intra-abdominal  pressure  displaces  downwards  a  definite  por- 
tion of  the  pelvic  floor,  viz.,  all  lying  in  front  of  the  anterior  rectal  wall. 

There  is  in  the  pelvic  floor  a  definite  line  of  cleavage  at  which  it  yields, 
which  line  runs  between  the  anterior  rectal  and  posterior  vaginal  walls 
(see  p.  63).  This  definite  downward  displacement  causes  the  lesion 
known  as  prolapsus  uteri. 

From  this  we  see  that  the  female  pelvic  floor  is  not  equally  strong 


FIG.  58. 

DIAORAX  to  illustrate  effect  of  intra-abdominal  pressure  on  the  segments  of  the  pelvic  floor  (Hart). 

a  Uterus  pathologically  anteflexed  ;  6  Bladder ;  c  Eetropubic  fat ;  d  Labium  majus ; 

e  Symphysis  ;  /  Perineal  body  ;  g  Rectum. 

throughout  It  would  be,  were  the  sacral  segment  prolonged  and 
attached  to  the  symphysis  pubis.  But  then  parturition  would  be 
an  impossibility.  It  has  been  constructed  not  only  qud  intra-abdominal 
pressure,  but  also  qud  parturition  and  the  vesical  and  rectal  functions. 


Effect  of 
change  of 


THE    RESULTS   BROUGHT   ABOUT    BY    CHANGE    OF   POSTURE,    ESPECIALLY 
BY    THE   GENUPECTORAL   POSTURE. 

The  abdominal  walls,  along  with  the  viscera  bounded  by  them,  are 
often  spoken  of  as  the  abdominal  cavity  with  its  contained  viscera.  We 
must,  however,  keep  in  mind  that  this  cavity  is  always  perfectly  full. 
There  is  never  any  vacuum  in  it.  The  viscera  are  always  in  apposition, 
with  only  a  little  fluid  as  a  film  separating  them.  The  abdominal  walls 


PHYSICS   OF  ABDOMEN  AND   PELVIS. 


77 


are  yielding,  and  any  tendency  to  a  vacuum  is  counteracted  by  atmo- 
spheric pressure  011  the  walls.  In  no  posture,  is  there  ever  a  vacuum  in 
the  abdominal  cavity.  Even  if  the  trunk  were  inverted,  the  small  intes- 
tines would  still  touch  the  uterus  as  they  do  in  fig.  45  and  Plate  V. 
The  abdominal  walls  and  viscera  enclosed  by  them  behave,  therefore, 
like  a  plastic  viscous  fluid — like  so  much  thick  gum  or  treacle. 

In  the  upright  posture,  the  viscera  bulge  above  the  symphysis  pubis, 
more  or  less,  according  to  the  development  of  the  subject.  Plate  IV. 
shows  this  bulging  in  a  well-formed  female  ;  the  bulging  is  excessive  if 
the  woman  is  fat.  Just  below  the  sternum,  the  antero-posterior 
diameter  of  the  abdomen  is  lessened.  The  pelvic  floor  is  convex  as 


FIG.  59. 

OUTLINE  OF  FEMALE  FIGURE  IN  GENUPECTORAL  POSTURE.  The  dotted  line  indicates  the  contour 
when  the  vaginal  orifice  is  unopened  ;  the  continuous  line,  the  change  in  contour  after  air  is 
admitted  into  the  vagina  (Simpson  and  Hart). 


seen  from  without,  i.e.,  the  pelvic-floor  projection  is  well  marked. 
Atmospheric  pressure  is  acting  equally  all  over  the  abdominal  and 
pelvic  surfaces  ;  but  the  pelvic-floor,  bearing  the  weight  of  the  viscera 
probably  bulges  more  than  the  other  boundaries  of  the  abdomen.  A 
fluid  contained  in  a  bag  suspended  from  a  fixed  point  is  pyriform,  with 
the  bulb  nearer  the  earth.  This  shape  is  due  to  the  weight  of  the 
fluid. 

If  a  man  be  made  to  assume  the  posture  known  as  the  genupectoral 
(better  genufacial),  the  bulge  is  at  the  sternum.  The  following  points 
should  be  noted  in  regard  to  this  posture  (fig.  59) : — 

1.  The  antero-posterior  diameter  of  the  abdominal  cavity  is  increased 
at  the  sternum ; 

2.  It  is  diminished  above  the  pubes  and  in  the  iliac  fossae ; 

3.  The  pelvic-floor  projection  is  diminished  ; 

4.  The  pubic  and  sacral  segments  are  still  in  contact,  and  the  abdo- 
minal viscera  always  in  contact  with  the  uterus  and  one  another. 


78 


A.  Y  ATOMY  OF  PELVIS. 


Upright      1 
and  Genu- 
pectoral 
Postures 
contrasted. 


Let  us  now  contrast  these  postures. 

Upright  posture  (Plate  IV.). 
Greatest    antero-posterior    (a-p} 

diameter  of  abdomen  in  hypo- 

gastrium  . 
Leagt  a_p  diameter  at  sternum. 


its 


Genupectoral  posture  (fig.  59). 

1.  Greatest    antero-posterior   dia- 
meter  at  sternum. 


2.  Least  a-p  diameter  in  hypogas- 

trium. 

3.  Pelvic-floor   projection    dimin- 

ished. 

4.  Pelvic-floor  sements  in  contact. 


3.  Pelvic-floor    projection     at 

maximum. 

4.  Pelvic-floor  segments  in  contact. 

In  the  latter  posture,  on  inspection  of  the  genitals,  the  labia  can  be 
seen  to  be  furrowed  and  the  skin  over  the  ischiorectal  fossa  slightly 
hollowed.  If  now  the  labia  majora  and  minora  be  separated  and  the 
fourchette  lifted  up,  no  further  change  as  yet  takes  place  :  but  when  the 
hymen  is  opened  up,  air  passes  into  the  vagina  (often  with  a  distinct 
hiss),  and  the  vaginal  walls  become  separated,  enclosing  a  somewhat  large 
cavity.  The  bulge  at  the  sternum  is  now  slightly  increased,  while  the 
diameter  in  the  hypogastrium  is  diminished  (see  fig.  59).  It  is  only  ivhen 
the  anatomical  entrance  of  the  vagina  (the  hymeneal  orifice)  is  opened  up, 
that  tJie  vagina  distends  with  air. 

It  has  been  shown  by  A.  R.  Simpson  and  D.  Berry  Hart,  that  the 
segments  of  the  pelvic  floor  separate  from  each  other  when  a  woman 
assumes  the  genupectoral  posture  and  the  hymeneal  orifice  is  opened. 
The  pubic  segment  passes  down  with  the  viscera  ;  the  sacral  segment 
remains  behind,  recoiling  slightly  upwards.  Thus,  functionally,  the  pubic 
segment  is  visceral,  the  sacral  one  is  vertebral. 

They  have  shown  further  that  there  is  a  definite  displacement  of  the 
pubic  segment  constituents,  viz.  :  — 

a.  The  empty  bladder  is  partly  above  the  pubes  ; 

6.  The  peritoneum  passes  from  abdominal  wall  to  bladder,  at  a  point 
1^  inches  above  the  symphysis; 

c.  The  retropubic  fat  is  partly  above  and  partly  below  the  top  of  the 
symphysis.  We  may  now  once  more  contrast  these  postures. 


Result  of  Upright  posture  (Plate  IV.). 

•  li-t.-iitimi 

of  Vagina 

with  Air.    1.  Pubic  and   sacral    segments   in 

apposition  and  vagina  a  slit. 

2.  Retropubic  fat  behind  pubes. 

3.  Empty  bladder  behind  pubes. 


Genupectoral  posture  (vagina  dis- 

.     . 

tended  with  air)  (fig.  60). 

1.  Pubic    and    sacral     segments 

separated  and  vaginal  walls 
bounding  a  cavity. 

2.  Retropubic    fat    partly   above 

pubes. 

3.  Empty   bladder    partly   above 

pubes. 


PHYSICS   OF  ABDOMEN  AND   PELVIS. 


79 


5. 


4.  Peritoneum  passes  from  anterior 

abdominal  wall  to  fundus  of 
empty  bladder,  immediately 
above  symphysis. 

5.  Urethra  and  bladder  meet  at   a 

right  angle. 

The  reason  why  the  pubic  segment  passes  downwards  when  the 
vaginal  orifice  is  opened  is,  that  atmospheric  pressure  now  acts  on  the 
vaginal  aspect  of  the  pubic  segment  (with  its  movable  attachment 
to  the  pubes)  and  drives  it  further  down.  As  the  result  of  this  posture, 


4.  Peritoneum  passes  from  anterior 
abdominal  wall  to  fundus  of 
empty  bladder,  1^  inches 
above  symphysis. 
Urethra  and  bladder  almost  in 
same  line. 


FIG.  60. 

PELVIS  FROM  FROZEN  SECTION  OF  CADAVER  IN  GEXUPECTORAL  POSTURE.  A  anus ;  P  perineum ; 
R  rectum  ;  V  vagina  ;  u  urethra  ;  B  bladder ;  /  retropubic  fat ;  U  retroverted  uterus  ;  pp  peri- 
toneum. Between  the  small  intestine  and  peritoneum  is  fatty  omentum.  (Simpson  atid  Hart.) 

changes  take  place  in  the  length  and  direction  of  the  vaginal  walls  and 
in  the  position  of  the  uterus. 

1.    Vagina. — (a.)  Both  walls  elongate. 

(b.)  The  anterior  follows  the  direction  of  the  posterior 


80  ANATOMy  OF  PELVIS. 

aspect  of  the  symphysis ;  the  posterior,  the  curve 
of  the  sacrum. 
2.  Uterus. — (a.)  The  normally  placed  uterus  passes  nearer  the  sacrum 

and  nearer  the  thoracic  diaphragm. 
(6.)  The  retroverted  uterus,   fixed  or  unfixed,  becomes 

more  retroverted. 

(c.)  The   retroverted   unfixed   uterus   does    not   become 
replaced  so  as  to  lie  anteverted. 

The  results  given  have  been  obtained  as  follows  : — 

a.  By  observation  on  living  patients,  aided  by  silhouettes  of  the  out- 
lines of  the  nude  body  in  the  upright  and  genupectoral  postures ; 

b.  By  study  of  frozen  sections  of  the  female  pelvis,  and  especially  by 
study  of  a  frozen  section  of  a  cadaver   placed   in   the   genupectoral 
posture. 

For  further  details  on  this  subject  Simpson  and  Hart's  atlas  may  be 
consulted. 

An  important  practical  result  follows  from  these  observations.  The 
vagina  dilates,  or,  more  properly,  the  segments  of  the  pelvic  floor  separate 
exposing  their  free  margins — the  vaginal  walls — when  a  patient  assumes 
the  genupectoral  posture  and  the  hymeneal  orifice  is  opened  so  as  to  admit 
air.  If  a  patient  be  so  placed  opposite  a  good  light,  and  the  sacral 
segment  be  drawn  up,  a  complete  view  of  the  vaginal  walls  and  cervix 
is  obtained.  The  same  results  can  be  got  by  placing  the  patient 
in  the  posture  known  as  the  semiprone.  On  this  last  fact  is  based 
the  use  of  the  vaginal  speculum  known  as  Sims'  or  duckbill  speculum 
(v.  Chap.  XL). 

THB   EFFECT    ON    UTERINE    POSITION    OF   DIGITAL    PRESSURE    IN    THE 
VAGINAL    FORNICES. 

This  is  a  subject  of  great  practical  importance. 

Effect  of         If,  when  a  patient  is  lying  on  her  left  side,  the  index  finger  of  the 

Pressure     examiner's  right  hand  is  passed  into  the  vagina  as  far  as  the  posterior 

fornix,  and  pressure  made  there,  the  following  results  may  be  noted  : — 

(1.)  The  posterior  vaginal  wall  is  elongated,  the  cervix  drawn  back, 
and  the  uterus,  if  anteverted,  becomes  more  so. 

(2.)  If  the  uterus  is  retroflexed,  the  flexion  is  not  remedied.  Should 
the  fundus  be  fixed,  the  retroflexed  is  increased  as  the  cervix  is  drawn 
back  while  the  fundus  remains. 

Similarly,  if  pressure  be  made  in  the  anterior  fornix  : — 

(1.)  The  uterus  becomes  elevated  and  slightly  rotated  backwards, 
because  the  cervix  is  pulled  forwards. 

(2.)  If  the  uterus  is  anteflexed,  the  flexion  is  not  diminished. 


PHYSICS   OF  ABDOMEN  AND   PELVIS.  81 

By  pressure  in  these  fornices,  therefore,  we  only  act  on  the  cervix, 
unless  the  uterus  is  very  much  retroverted  or  anteverted.  The  body 
of  the  uterus  is  acted  on  only  indirectly,  through  its  union  with  the 
cervix. 

Consequently,  no  vaginal  pessary  can  undo  the  flexion  of  a  retroflexed 
or  anteflexed  uterus. 


CHAPTER    VII. 

MENSTRUATION  AND  OVULATION. 

LITERATURE. 

Beiffel—Die  Krankheiten  des  weiblichen  Geschlechtes :  F.  Enke,  Stuttgart,  1875. 
Dalton— Report  on  the  Corpus  Luteum  :  Am.  Gyn.  Tr.,  Vol.  II.,  p.  11.  Physiology, 
6th  edition,  J.  &  A.  Churchill,  1876.  Engelmann — The  Mucous  Membrane  of  the 
Uterus,  with  especial  reference  to  the  Development  and  Structure  of  the  Decidua  : 
Am.  J.  of  Obst.,  Vol.  VIII.,  p.  30.  Prey's  Histology— Barker's  Tr.,  1874.  Goodman 
— The  Cyclical  Theory  of  Menstruation  :  Anier.  Jour,  of  Obstet.,  Oct.  1878.  Jacobi 
••-The  Question  of  rest  for  women  during  Menstruation :  Smith,  Elder  &  Co.,  London, 
1878.  Kinkead — On  the  passage  of  the  Ovum  from  the  Ovary  into  the  Fallopian  Tubes : 
Med.  Press,  September  14, 1881.  Kundrat — Untersuchungen  liber  die  Uterusschleim- 
haut :  Strieker's  Jahrbuch,  1873.  (Kundrat  and  Engelmann  were  co-workers. )  Leopold 
— Studien  iiber  die  Uterusschleimhaut  wahrend  Menstruation,  Schwangerschaft  und 
Wochenbett:  Archiv  fur  Gynak.,  Bd.  XL,  S.  1091.  Untersuchungen  iiber  Men- 
struation und  Ovulation  :  Archiv  f.  Gyn.,  Bd.  XXI.,  S.  347.  Loewenhardt — Die 
Berechnung  und  die  Dauer  der  Schwangerschaft:  Archiv  fur  Gynak.,  Bd.  III.,  S. 
456.  Moricke — Die  Uterusschleimhaut  in  den  verschiedenen  Altersperioden  und  zur 
Zeit  der  Menstruation:  Ztschr.  filr  Geburtshiilfe  und  Gynak.,  VII.  Band,  1  Heft, 
1881.  Reinl — Die  "Wellenbewegung  der  Lcbensprocesse  des  "Weibes :  Volkmann's 
Sammlung,  etc.,  No.  243.  Ritchie,  C.  G. — Contributions  to  Ovarian  Physiology  and 
Pathology  :  Churchill,  London,  1865.  Simpson,  A.  Russell — Emmenologia  ;  Contri- 
butions to  Obstetrics  and  Gynecology  :  Edinburgh,  A.  and  C.  Black.  Stephenson— 
On  the  Menstrual  Wave  :  Amer.  Jour,  of  Obstet.,  April  1882.  Tait,  Lawson — Br. 
Med.  Journ.,  June  4,  1881.  Notes  on  the  Relations  of  Ovulation  and  Menstruation  : 
Medical  Times,  London,  1884.  Underhill—Note  on  the  Uterine  Mucous  Membrane 
of  a  Woman  who  died  immediately  after  Menstruation :  Ed.  Med.  J.,  1875. 
Williams— On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,  and  its 
periodical  changes  :  London  Obst.  Jour.,  Vol.  II.,  p.  681.  Wyder— Das  Verhalten 
der  Mucosa  Uteri  wahrend  der  Menstruation :  Zeit.  f.  Geburtshiilfe  und  Gynak., 
Bd.  IX.,  Hft.  1.  See  also  Index  of  Recent  Gynecological  Literature  in  Appendix. 

THE  subject  of  Menstruation  is  not  as  yet  well  known,  and  on  many 
points  eminent  and  trustworthy  observers  are  at  variance.  The  nature 
of  the  process  is  at  present  sub  lite.  The  old  theories  of  its  being  due 
to  plethora  or  its  being  a  disease  are  now  exploded.  The  modern  view, 
termed  the  ovulation  theory,  asserts  that  the  starting  point  in 
menstruation  is  the  bursting  of  a  Graafian  follicle.  But  in  cases  of 
.abdominal  section  performed  between  the  menstrual  periods,  as  has 
been  specially  observed  by  Tait  and  Leopold,  Graafian  follicles  have 
been  found  on  the  point  of  bursting,  clearly  showing  that  ovulation  may 
in  certain  cases  occur  remote  from  menstruation.  The  only  objection 
that  may  be  urged  to  this  is  that  abdominal-section  cases  are  not 
normal.  Ritchie,  however,  long  ago  insisted  on  the  same  view. 


MENSTRUATION  AND   OVULATION.  83 

Jaeobi,  Stephenson  and  Reinl  (working  on  Goodman's  cyclical 
theory)  have  given  good  proof  that  a  woman  in  her  full  sexual 
vigour  seems  to  pass  through  a  series  of  cyclical  changes,  of  each  of 
which  the  menstrual  period  is  the  climax.  Jaeobi  found  that,  during 
the  few  days  before  the  flow,  the  excretion  of  urea  is  increased ;  the 
temperature  is  slightly  raised ;  and  that,  in  regard  to  the  pulse,  there 
is  a  rhythmic  wave  beginning  at  a  minimum  point  1  to  4  days  after  the 
cessation  of  the  flow  and  gradually  rising  to  a  maximum  7  or  8  days 
before  menstruation.  So  far  as  our  present  knowledge  goes,  the  follow- 
ing is  a  brief  resume. 

PRELIMINARY    CONSIDERATIONS^ 

Definition. — A  cyclical  change  with  constitutional  disturbances  whose Prelimi- 
most  marked  local  phenomena  are  periodical  flow  of  blood  from  the  uterine  na 
cavity,  with  shedding  of  the  superficial  layers  of  its  mucous  membrane, 
accompanying  (according  to  the  hitherto  accepted  theory)  the  discharge 
of  an  ovum  from  the  ovary,  occurring  in  properly  developed  women 
between  the  ages  of  14  and  44,  and  interrupted  by  uterogestation  and 
lactation. 

Period  of  its  Onset. — Menstruation  begins,  in  this  country,  usually  at 
the  age  of  13  to  15  (puberty).  It  may  be  delayed  till  16,  17,  or  20; 
but  this  is  unusual.  Its  onset  is  earlier  in  warm  countries,  later  in  cold 
ones  ;  earlier  in  delicately  nurtured  girls. 

Period  of  its  Cessation. — With  the  interruptions  of  pregnancy  and 
lactation,  it  continues  in  healthy  women  until  the  age  of  44  to  50.  The 
period  of  its  final  cessation  is  known  as  the  menopause.  As  a  general 
rule  the  menopause  is  early  when  menstruation  has  begun  early,  and 
vice  versa. 


GENERAL    PHENOMENA    OF    MENSTRUATION. 

Changes  at  Puberty. — At  this  period  of  life,  when  the  girl  becomes  the  General 

Pheno 
mena. 


-woman,  we  find  certain  well  marked  general  changes  occurring.     The^ 
bust  and  inons  veneris   develop   and  the  whole   contour  of  the  body 
becomes  more  rounded  and  attractive ;   hair  appears  on  the  genitals. 
The  romping  carriage  of  the  girl  becomes  subdued,  and  greater  shyness 
characterises  her  conduct  to  the  opposite  sex. 

Phenomena  premonitory  to  each  menstrual  flow. — There  is  usually  a 
feeling  of  weight  in  the  pelvis  and  increase  of  sexual  inclination.  Many 
women,  however,  have  very  little  uneasiness  during  the  whole  flow  ; 
while  others  are  always  considerably  distressed, — this  distress  being 
istill  outside  the  boundary  of  actual  disease. 

Periodicity  and  duration  of  Discharge. — When  once  established  it 
recurs,  in  the  large  majority  of  cases  (about  87  p.  c.  of  the  whole),  with 
great  regularity  :  the  most  common  intervals  are  28  days  (in  71-p.  c.) 


84  PHYSIOLOGY  OF  PELVIS. 

and  30  days  (in  14-  p.  c.);  less  frequent  are  21  days  (in  2-  p.  c.) 
and  27  days  (in  1  +  p.  c.).  We  speak  therefore  of  the  21  day  type  and 
so  on.  The  discharge  lasts  for  a  number  of  days,  varying  from  2  to  8  : 
if  below  2  or  above  8  it  is  abnormal ;  but  of  course  other  points  besides 
mere  duration  must  be  taken  into  account. 

LOCAL  PHENOMENA. 

Local  Three   periods   are   distinguished:    1.    Invasion;    2.    Persistence;  3. 


1.  Invasion. — Discharge  pale. 

2.  Persistence. — Discharge   bright   red,  non-coagulable   from   its  ad- 
mixture with  mucus.      It  consists  microscopically  of  epithelium  from 
vaginal,  cervical,  and  uterine  cavities ;   mucous  globules ;    compound 
granular  corpuscles ;  and  red  and  white  blood-corpuscles. 

3.  Decline. — Discharge  lessens  in  amount  and  becomes  lighter  in  colour. 
The  total  quantity  varies  from  2  to  8  ounces. 

Thus  far  we  have  related  facts  fairly  well  ascertained  and  not  much 
disputed.  We  now  enter  on  more  debateable  ground,  in  considering — 

I.  Ovulation ; 
II.  The  Corpus  luteum ; 

III.  Source  of  discharge,  and  changes  in  the  uterine  mucous  membrane. 
Ovnlation.       I.   Ovulation. — According  to  the  ovulation  theory,  ovulation  forms  the 
starting  point  of  the  process  of  menstruation.     We  have  already  con- 
sidered the  structure  and  development  of  the  ovary,  and  now  describe 

The  changes  in  the  Ovary  at  each  Menstrual  Period. — A  Graafian  follicle 
enlarges  and  moves  nearer  the  surface.  Probably  this  produces,  through 
a  nervous  mechanism,  a  hypersemia  of  the  whole  pelvic  contents, — peri- 
toneum, connective  tissue,  uterus,  ovaries,  Fallopian  tubes,  and  vagina. 
It  is  alleged,  as  yet  on  insufficient  grounds,  that  the  fimbriated  end  of 
the  Fallopian  tube  grasps  the  ovary,  and  that  the  ovum  from  the  ruptured 
Graafian  follicle  passes  into  it  and  along  the  tube  to  the  uterine  cavity. 
Professor  Kiukead  of  Galway  has  recently  advanced  another  explanation. 
He  points  out  that,  between  the  fimbriated  end  of  the  Fallopian  tube  and 
the  ovary,  we  have  the  ovarian  fimbria  (fig.  20)  forming  a  groove  which 
is  converted  into  a  tube  by  the  surrounding  viscera ;  and  that  we  have 
thus  capillary  action  towards  the  uterus.  This  would  lead  the  ovum 
into  the  Fallopian  tube.  However  it  reaches  the  Fallopian  tube  and 
uterus,  its  further  development  depends  on  its  fertilization  or  non- 
fertilization.  In  the  latter  case  it  passes  off  unnoticed  in  the  menstrual 
discharge ;  in  the  former  it  developes  into  the  foetus. 

lun'u,"  IL  The  CorPus  tut™™.— After  the  rupture  of  the  Graafian  follicle,  we 

;s  cavity  filled  up  by  the  structure  known  as  the  corpus  luteum 

This  is  formed  by  proliferation  of  the  cells  of  the  membrana  granulosa 


MENSTRUATION  AND   OVULATION. 


85 


by  the  sprouting  of  new  capillaries  with  migratory  cells  into  the  hyper- 
trophied  convoluted  epithelium.  The  central  portion  degenerates  into 
gelatinous  tissue,  the  cortical  into  fatty  tissue  (Klein  and  Smith). 

The  corpus  luteum  thus  consists  of  a  vascular  framework,  with  a 
yellow  pigmentary  and  cellular  substance.  It  varies  according  as 
pregnancy  does  or  does  not  follow  its  formation.  The  difference  is  well 
given  in  Dalton's  table,  which  we  subjoin. 


CORPUS  LUTEUM  OP 
MENSTRUATION. 

COKPUS  LUTEUM  OP  PREGNANCY. 

End  of  3  weeks. 

12  by  13  mm.  in  diameter  ; 

central  clot  reddish,  con- 

voluted wall  pale. 

One  month. 

Smaller;   convoluted  wall 

Larger  ;     convoluted    wall    bright 

bright  yellow;   clot  still 

yellow  ;  clot  still  reddish. 

reddish. 

Two  months. 

Insignificant  cicatrix. 

12  by  22  millimetres  in  diameter; 

convoluted    wall    bright    yellow; 

clot  perfectly  decolorized. 

Four  months. 

Absent  or  unnoticeable. 

18  by  22  millimetres  in  diameter; 

clot    pale    and    fibrinous  ;     con- 

voluted wall  dull  yellow. 

Six  months. 

Absent. 

Still  as  large  as  at  the  end  of  the 

second    month  ;    clot    fibrinous  ; 

convoluted  wall  paler. 

Nine  months. 

Absent. 

10  by  13  millimetres  in  diameter; 

central     clot     converted    into    a 

radiating  cicatrix  ;   external  wall 

tolerably    thick    and    convoluted, 

but    without    any    bright    yellow 

colour. 

III.  /Source  of  Discharge  and  CJianges  in  the  Uterine  Mucous  Mem-  Source  of 
brane. — All  observers  are  agreed  that  the  mucous  membrane  of  the    * 
uterine  cavity  is  the  source  of  the  discharge,  i.e.,  that  it  comes  from  the 
area  limited  by  the  uterine  ends  of  the  Fallopian  tube  and  the  os 
internum. 

Now  begins  the  divergence. 

(1.)  Williams  holds  that  "  uterine  contraction  drives  the  blood  from  "\yilliams' 
the  muscular  wall  into  the  mucous  membrane ;  the  vessels  of  this  mem-™ 
brane,  having  undergone  fatty  degeneration,  give  way,  and  extravasation 
of  blood  results.  This  extravasation  takes  place  always  near  the  surface, 
for  in  that  situation  the  degenerative  change  has  most  advanced.  The 
rush  of  blood  into  the  vessels  of  the  mucous  membrane  expels  the  contents 
of  the  glands,  together  with  the  greater  part  of  their  lining  epithelium. 
When  haemorrhage  has  taken  place  into  the  membrane,  it 
undergoes  rapid  disintegration,  and  becomes  entirely  removed."  The 
new  mucous  membrane  "  is  produced  by  proliferation  of  the  elements 
of  the  muscular  wall  of  the  organ  :  the  muscular  fibres  producing  the 
fusiform  cells ;  the  connective  tissue,  the  round  cells ;  and  the  groups 


86 


PHYSIOLOGY  OF  PELVIS. 


of  round  cells  in  the  meshes  formed  by  the  muscular  bundles,  the 
glandular  epithelium."  These  "groups  of  round  cells  "  may  be  the  ter- 
minations of  the  uterine  glands. 

In  a  more  recent  paper,1  Williams  has  modified  the  statement  of  his 
view  by  affirming  that  the  greater  portion  of  the  muscular  wall  of  the 
uterus  represents  the  muscularis  mucosse.  According  to  this,  only  the 
glandular  portion  of  the  mucous  membrane  is  shed. 

Entire  removal  of  the  mucous  membrane  down  to  the  muscular  fibre,  and 
its  regeneration  from  groups  of  round  cells  in  the  muscular  coat,  are  the 
essentials  of  Williams'  view. 


.  Kundrat 


FIG.  61. 

DIAGRAM  of  UTERUS  just  before  MENSTRUA- 
TION. The  shaded  portion  represents  the 
Mucous  MEMBRANE  (/.  Williams). 


FIG.  62. 

DIAGRAM  of  UTERUS  when  MENSTRUATION 
has  just  ceased,  showing  the  cavity  of  the 
body  deprived  of  Mucous  MEMBRANE  (/. 
Williams). 


(2.)  Kundrat  and  Engelmann  thus  describe  the  changes. 

Mucous  membrane  becomes  swollen  and  pulpy,  and  measures  in  thick- 
ness 3-6  mm.  The  thickness  is  most  marked  at  the  fundus  and  central 
portions  of  the  anterior  and  posterior  surfaces.  The  surface  is  puffy  and 
injected  ;  glands  are  distinctly  seen  on  section  as  fine  spirals. 

Microscopically,  this  increase  in  thickness  is  seen  to  be  due  to  a  pro- 
iferation  of  the  round  cells  of  the  stroma,  an  enlargement  of  all  the  cell 

ements  in  the  superficial  layers,  and  an  increase  of  the  intercellular 

stance.     This  superficial  layer  has  grown  far  above  the  original  gland 

ungs,  causing  the  funnel-shaped  depressions  or  small  pits  seen  on 

1  On  the  Circulation  of  the  Uterus,  etc.  :  Lond.  Obs.  Trans.,  1885. 


MENSTRUATION  AND   OVULATION. 


87 


surface  view.  The  glands  are  increased  in  thickness  and  length.  The 
vessels  are  enlarged  and  gorged  with  blood.  Fig.  63  shows  the 
mucous  membrane  of  the  menstruating  uterus  magnified  40  times ;  it 
should  be  compared  with  the  mucous  membrane  of  the  non-menstruating 
uterus  at  fig.  17,  also  magnified  40  times. 

The  increase  of  the  thickness  of  the  mucous  membrane  begins  as  the 
time  of  menstruation  approaches,  is  most  marked  during  the  period  itself, 
and  gradually  decreases  after  the  cessation  of  the  catamenial  flow. 


FIG.  63. 

Mucous  MEMBRANE  OF  MENSTRUATING  UTERUS  (Kundrat  and  Engdmann).  (*f) 

Fatty  degeneration  takes  place  in  the  cells  of  the  interglandular  tissue, 
blood-vessels,  and  glandular  and  surface  epithelium. 

They  hold  that  "  the  haemorrhage  is  always  confined  to  the  surface  of 
the  lining  membrane,  and  is  due  to  the  fattily  degenerated  tissue  being 
unable  to  resist  the  blood  pressure ; "  and  they  therefore  maintain,  what 
is  most  probably  the  case,  that  only  the  superficial  layer  of  the  mucous 
membrane  is  shed  at  a  menstrual  period. 


88  PHYSIOLOGY  OF  PELVIS. 

Leopold's  (3.)  Leopold  denies  the  existence  of  any  fatty  degeneration  of  the 
superficial  layers  of  the  mucous  membrane.  He  believes  that  an  extra- 
vasation of  red  and  white  blood  corpuscles  from  the  superficial  capillaries 
takes  place  especially  towards  the  superficial  layer,  undermining  the 
uppermost  layer  of  cells ;  and  that,  finally,  the  copious  supply  of  blood 
reaching  these  capillaries  from  the  numerous  arteries  causes  rupture  and 
bleeding.  The  mucous  membrane  is  regenerated  by  an  upward  growth 
of  the  glandular  epithelium. 

MSricke'a  Williams,  Kundrat,  Engelmann,  and  Leopold  examined  uteri  from 
post-mortem  cases.  Recently  Moricke  has  curetted  the  uteri  of  living 
women  at  various  stages  of  menstruation,  and  microscopically  examined 
what  he  removed.  He  asserts  "  that  during  menstruation  the  mucous 
membrane  disappears  neither  partially  nor  fully."  This  shows  how 
widely  microscopists  vary.  Williams  says  all  the  mucous  membrane 
down  to  the  uterine  muscle  is  removed;  Kundrat,  Engelmann,  and 
Leopold  say  only  the  superficial  layers  are  removed ;  and  Moricke  says 
none  is  removed. 

We  have  deemed  it  best  to  lay  these  views  before  the  student.  The 
subject  is  difficult  to  investigate,  and  one  on  which  the  authors  are  not 
qualified  to  give  an  opinion.  They  incline,  however,  to  the  views  of 
Kundrat,  Engelmann,  and  Leopold. 

A  dispute  still  exists  as  to  which  ovum  is  fertilised  when  pregnancy 
occurs — the  ovum  of  the  last  menstruation,  or  that  of  the  first  period 
missed.  Many  observers  believe  in  Loewenhardt's  theory,  viz.,  that  the 
ovum  fertilized  is  that  of  the  first  period  missed. 

Lately  the  dominant  influence  of  the  ovary  in  menstruation  has  been 
questioned  by  some,  notably  by  Lawson  Tait.  The  operation  known  as 
Battey's  operation,  where  both  ovaries  are  removed,  does  not  always 
cause  a  cessation  of  menstruation.  Tait  asserts  that  menstruation  will 
always  cease  if  the  Fallopian  tubes  also  are  excised ;  and  therefore 
believes  that  they  play  an  important  part  in  menstruation,  hitherto 
unsuspected. 

Leopold's  monograph  is  illustrated  by  many  valuable  lithographs,  and 
the  same  may  be  said  in  regard  to  Dalton's  work  on  the  Corpus  Luteum. 


SECTION   II. 

PHYSICAL  EXAMINATION  OF  THE  FEMALE  PELVIC 
ORGANS. 

TN  this  section  we  have  to  take  up  the  physical  examination  of  the 
-*-  female  pelvic  organs — that  is,  exploration  by  the  hands  and  instru- 
ments of  the  gynecologist.  This  will  be  considered  in  the  following 
manner. — 

CHAPTER  VIII.     Abdominal  Examination;  Vaginal  Examination;  the 
Bimanual  Examination,  with  its  various  modifications. 

CHAPTER  IX.  Examination  per  Rectum. 

CHAPTER  X.  The  Volsella. 

CHAPTER  XI.  Vaginal  Specula. 

CHAPTER  XII.  The  Uterine  Sound. 

CHAPTER  XIII.  Tents  and  other  Uterine  Dilators. 

CHAPTER  XIV.  The  Curette. 

CHAPTER  XV.  Knives ;   Scissors  ;   Needles ;   Sutures ;    Douches    and 
Syringes ;  Anaesthetics. 

CHAPTER  XVI.  Relation  of  Micro-organisms   to   Gynecology;    Anti- 
septics. 


CHAPTER  VIII. 

ABDOMINAL  EXAMINATION;   VAGINAL  EXAMINATION; 

THE  BIMANUAL  EXAMINATION,  WITH  ITS  VARIOUS 

MODIFICATIONS. 

IN  a  female  patient  whose  symptoms  point  to  a  pelvic  cause,  it  is  neces- 
sary to  investigate  the  case  by  what  is  commonly  known  as  a  vaginal 
examination.  A  mere  vaginal  examination,  however,  gives  very  little 
information.  The  proper  method  is  first  to  make  an  external  abdominal 
examination  and  then  the  vaginal  examination,  the  latter  being  only 
a  stage  of  the  more  complete  method  of  investigation  known  as  the 
bimanual.  Special  cautions  as  to  cases  unsuitable  for  pelvic  exploration 
are  given  under  the  head  of  vaginal  examination.  We  consider  the 
examination  in  the  following  order : — 

I.  External  abdominal  examination  ; 
II.  Inspection  of  external  genitals  (only  when  necessary)  ; 

III.  Vaginal  examination ; 

IV.  The  bimanual  (abdomino-vaginal)  examination. 

EXTERNAL   ABDOMINAL    EXAMINATION. 

External         The  patient  should  lie  on  the  back,  with  knees  drawn  xip,  and  head 

E^mTiir1 8UPPorted  on  a  pillow.     The  bowels  and  bladder  should  be  empty.     The 

tion.          abdominal  surface  should  be  exposed  from  the  epigastrium  downwards  ; 

no  part  of  the  mons  veneris  should  be  uncovered.     The  most  delicate 

method  of  accomplishing  this  is  as  follows.     A  sheet  or  blanket  is  thrown 

over  the  recumbent  patient ;  beneath  this  she  raises  up  her  dress  as  far 

as  the  pit  of  the  stomach  ;  the  examiner  then  places  his  one  hand  on  the 

sheet,  a  little  above  the  mons  veneris,  and  turns  it  down  over  it  with 

his  other  hand.     The  abdominal  surface  is  examined  in  four  ways,  viz., 

inspection,  palpation,  percussion,  auscultation. 

Inspection.  A.  Inspection. — The  form,  colour,  equality  or  inequality  of  bulge  of 
the  abdominal  surface  should  be  noted ;  the  presence  or  absence  of  the 
linea  nigra,  linese  albicantes  (fresh  and  old),  pigmentary  deposits,  fat 
streaks,  and  skin  eruptions.  The  linea  nigra  has  little  significance. 
The  linese  albicantes  indicate  that  the  patient's  abdominal  cavity  is 
or  has  been  distended  beyond  the  normal.  They  are  not  specially 
characteristic  of  pregnancy.  Fresh  linese  albicantes  are  glistening  and 
pearly ;  old  ones  have  a  dull-white  or  scarred  appearance. 


ABDOMINAL   EXAMINATION.  91 

B.  Palpation  should  be  performed  with  both  hands.  For  this  purpose  Palpation, 
the  hands,  well  warmed,  are  laid  flat  on  the  abdominal  surface ;  and  the 
whole  ai'ea  is  manipulated  between  them.  One  hand  alone  is  of  no  use. 
By  this  method  the  abdominal  contents  may  be  compressed  and  moved 
between  the  hands.  The  feeling  given  normally  is  that  of  manipulating 
a  plastic  fluid.  Tapping  with  one  index  finger  so  as  to  give  a  fluctuating 
impulse  to  the  other  hand  is  of  great  value.  Circumscribed  nodules  or 
tumours,  fluid  collections,  thickening  of  the  skin,  should  be  noted  and 
mapped  out  on  the  scheme  given  in  the  chapter  on  case-taking. 

For  the  more  exact  localisation  of  the  normal  and  abnormal  abdominal  Abdominal 
contents,  anatomists  divide  the  anterior  abdominal  surface  into  definite  reglons- 
regions  by  vertical  and  transverse  lines.     The  lower  transverse  line  is 
drawn  at  the  level  of  the  anterior  superior  iliac  spines ;  the  upper  one, 
between  the  most  prominent  parts  of  the  ninth  costal  cartilages.     A 
vertical  line  joining  the  cartilage  of  the  eighth  rib  with  the  middle  of 
Poupart's  ligament  on  each  side,  completes  the  division  into  nine  areas, 
which  are  named  in  order  as  follows  (vide  Plate  IV.). 

1.   Right  Hypochondriac.     2.  Epigastric.          3.  Left  Hypochondriac. 
4.       „       Lumbar.  5.  Umbilical.          6.     „      Lumbar. 

7.      ,,       Iliac.  8.  Hypogastric.     9.     „      Iliac. 

In  these  regions  the  following  structures  are  found. — 

Epigastric  Region. — Right  part  of  stomach  ;  pancreas;  liver. 

Right  HypocJiondriac. — Right  lobe  of  liver ;  gall  bladder ;  part  of  duo- 
denum ;  hepatic  flexure  of  colon ;  part  of  right 
kidney,  and  its  suprarenal  capsule. 

Left  Hypochondriac. — Cardiac  end  of  stomach  ;  spleen  and  narrow  ex- 
tremity of  the  pancreas ;  the  splenic  flexure  of  the 
colon;  the  upper  part  of  the  left  kidney,  with  the 
left  suprarenal  capsule  ;  sometimes  also  a  part  of 
the  left  lobe  of  the  liver. 

Umbilical. — Part  of  the  omentum  and  mesentery ;  the  transverse  part 
of  the  colon ;  lower  part  of  the  duodenum,  with 
some  convolutions  of  the  jejunum  and  ileum. 

Right  Lumbar. — The  ascending  colon  ;  lower  half  of  the  kidney;  and 
part  of  the  duodenum  and  jejunum. 

Left  Lumbar. — The  descending  colon  ;  lower  part  of  the  left  kidney,  with 
part  of  the  jejunum. 

Hypogastric. — The  convolutions  of  the  ileum ;  the  bladder  in  children, 
and,  if  distended,  in  adults  also ;  the  fundus  uteri 
when  the  bladder  is  distended. 

Right  Iliac. — The  caecum  with  the  appendix  vermiformis,  and  the  ter- 
mination of  the  ileum;  right  broad  ligament,  with 
its  ovary,  parovarium,  and  Fallopian  tube. 


92  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

Left  Iliac. — The  sigmoid  flexure  of  the  colon  ;  left  broad  ligament,  with 
its  ovary  and  Fallopian  tube. 

The  student  will  observe  that  the  above  table  mentions  several 
of  the  pelvic  organs  (uterus  and  its  appendages)  as  lying  in  the 
lower  regions  of  the  abdomen ;  this  is  done  because  the  obliquity  of 
the  brim  of  the  pelvis  brings  these  organs  to  lie  underneath  the 
regions,  in  which  consequently  any  marked  change  in  them  will  be 
recognised. 

Ruedinger's  Plate  V.  shows  a  valuable  coronal  section,  published  by  Ruedinger ; 
it  should  be  carefully  studied.  The  numbers  refer  to  the  following 
structures. 

1.  Right  lung.  2.  Right  auricle;  to  its  left  is  the  larger  coronary 
vein.  4.  Right  branch  of  pulmonary  artery.  The  shorter  left  branch  is 
seen  at  the  left.  7.  Liver.  Note  the  impression  on  its  under  and  right 
side  from  the  right  flexure  of  the  colon.  8.  Stomach.  Note  how  its 
long  axis  is  vertical,  and  that  the  main  bulk  of  the  stomach  is  to  the  left 
of  the  middle  line.  9.  Ascending  colon.  9*.  Opening  of  small  intes- 
tine. 10.  Small  piece  of  junction  between  stomach  and  duodenum.  11. 
Pancreas.  12.  Duodenum.  13-13.  Small  intestine.  14.  Fundus  uteri. 
15.  Bladder,  with  ureteric  openings.  16.  Connective  tissue.  17. 
Descending  colon.  18.  Sigmoid  flexure.  19.  Mesentery. 

For  the  relations  of  the  lower  regions  of  the  abdomen  to  the  pelvic 
contents,  the  student  might  consult  fig.  50,  which  shows  very  well  the 
latter  as  seen  through  the  brim. 

In  palpating  the  normal  abdomen,  the  sensation  given  is  one  of  impulse 
communicated  generally  through  a  plastic  fluid.  When  free  fluid  is  in 
the  abdominal  cavity,  the  impulse  is  more  distinct.  When  the  fluid  is 
encysted,  the  impulse  and  tense  feeling  are  localised. 

When  any  large  body  is  felt  in  the  abdominal  cavity,  the  first  point  to 
be  determined  is  whether  the  body  is  pelvic  or  abdominal.  This  is  easily 
done  by  attempting  to  press  the  hand  downwards  just  above  the  sym- 
physis  pubis.  If  the  tumour  is  pelvic,  and  rising  up  into  the  abdomen, 
the  hand  cannot  be  so  pressed ;  and  conversely. 

The  next  point  is  to  ascertain  with  which  of  the  organs  the  tumour  is 
connected ;  and,  for  this,  perfect  familiarity  with  the  topography  of  the 
viscera  is  of  the  highest  importance.  The  student  should  ask  himself 
what  structures  are  normally  present  in  the  region,  and  then  to  which 
of  these  the  tumour  is  to  be  referred ;  with  regard  to  the  iliac  regions 
he  should  bear  in  mind  the  frequency  of  inflammatory  deposits  in  the 
peritoneum  and  cellular  tissue,—  e.g.  in  the  right  iliac  region,  besides 
large  intestine,  broad  ligament,  ovary,  parovarium,  and  Fallopian  tube, 
there  are  peritoneum  and  cellular  tissue  in  both  of  which  inflammatory 
deposits  are  frequent. 

In  all  tumours,  the  existence  or  non-existence  of  intermittent  contrac- 


ABDOMINAL   EXAMINATION.  93 

tions  should  be  carefully  noted.  Their  presence  indicates  a  uterine 
tumour — pregnancy  or  soft  fibroid. 

The  following  general  points  should  be  kept  in  mind.  The  bladder  is 
only  in  the  hypogastric  region  when  distended  or  displaced  upwards ;  if 
empty,  it  is  behind  the  pubes  and  in  the  true  pelvis;  a  distended  bladder 
may  be  as  large  as  a  six  months'  pregnancy.  Ovarian  tumours  are  more 
or  less  lateral ;  uterine  tumours  generally  central,  although  the  pregnant 
uterus  has  usually  a  right  lateral  obliquity.  In  advanced  pregnancy,  the 
parts  of  the  foetus  can  be  distinctly  palpated.  Finally,  it  should  be  kept 
in  mind  that  in  all  cases  of  cystic  tumours  the  catheter  should  be  passed 
into  the  bladder,  for  an  obvious  reason. 

CASE. — Mrs  A.  was  sent  for  consultation  as  to  removal  of  internal  tumour.  On  exami- 
nation, a  cystic  tumour  was  felt  mesially  in  the  abdomen  and  reaching  up  to  umbilicus. 
Vaginal  and  bimanual  examinations  were  exceedingly  painful.  A  catheter  passed  into  the 
bladder  evacuated  a  large  amount  of  urine.  The  uterus  was  now  found  to  be  retroverted 
and  gravid  3^  months,  and  the  cystic  tumour  had  disappeared. 

Palpation  of  the  inguinal  region  is  of  great  importance  and  should  Palpation 
never  be  omitted.     Glandular  and  other  enlargements  in  this  position0 
may  be  the  following. — 

(1.)  Glands  enlarged  from  gonorrhoea.  There  are  usually  one  or  two — 
large,  painful,  and  often  suppurating. 

(2.)  Glands  enlarged  from  syphilis.  These  are  multiple,  hard,  small, 
painless,  and  never  suppurate  in  an  uncomplicated  case. 

(3.)  Glands  enlarged  from  vulvar  malignant  disease,  or  malignant 
disease  of  vagina  (lowest  ^)  or  urethra. 

(4.)  Femoral  or  inguinal  hernia. 

(5.)  Thrombosis  of  femoral  vein. 

C.  Percussion  is  to  be  made  in  the  usual  way.     To  perform  this  Percussion, 
thoroughly,  the  patient  should  be  percussed  (a)  when  on  her  back ;  (6) 

when  on  the  left  side ;  (c)  when  on  the  right  side ;  (d)  when  sitting  up. 
Changes  in  the  percussion  note  on  the  patient  changing  her  posture 
should  be  carefully  noted,  as  they  are  of  great  value  (vide  under  Ovarian 
Tumours  and  Ascites). 

D.  Auscultation  is  performed   with   the    ordinary  stethoscope.     TheAusculta- 
foetal  heart,  uterine  souffle,  and  friction  may  be  heard  by  it.     The  im- 
portance of  auscultation  is  evident.     Fostal  heart-sounds  indicate  preg- 
nancy ;  the  point  of  greatest  intensity  of  the  heart-sounds  indicates  the 

lie  of  the  child.  Uterine  souffle  and  no  heart-sounds  (after  4^  months) 
indicate  either  pregnancy  and  child  dead,  or  fibroid  tumour.  Ovarian 
cysts  have  no  souffle. 

Before  finishing  abdominal  examination,  the  patient  should  be  made 
to  raise  her  shoulders  by  grasping  the  examiner's  hands.  When  there 
is  no  encysted  abdominal  tumour,  the  recti  can  be  seen  to  flatten  the 
abdominal  contour ;  if,  however,  a  solid  or  cystic  tumour  be  present,  the 


94  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

contour  is  unaltered.     An  exception  should  be  made  in  the  case  of  thin- 
walled  cysts  not  tensely  filled,  where  the  recti  do  flatten  the  contour. 

INSPECTION   OF   EXTERNAL  GENITALS. 

Iwpection  This  should  not  be  made  a  routine  practice.  As  a  general  rule,  inspec- 
S2Tltion  of  the  genitals  should  only  be  made  when  there  is  local  tenderness, 
where  syphilis  or  gonorrhoea  is  suspected,  or  where  it  is  said  by  the 
patient  that  something  comes  down  at  the  vaginal  orifice.  Soft  chancres, 
hard  chancres  (almost  never  seen  in  females),  mucous  patches,  condy- 
lomata ;  urethral  caruncles ;  irritable  spots  causing  vaginismus ;  labial 
abscess;  parturition  tears  of  perineum  and  labia;  prolapsed  pelvic  organs; 
external  or  internal  piles,  may  be  found. 

VAGINAL   EXAMINATION. 

Vaginal  Preliminaries.—  Vaginal  examination  should  not  be  made  on  girls 
Examina-  below  or  little  beyond  the  age  of  puberty,  unless  the  symptoms  are 
urgent,  e.g.  mechanical  retention  of  menstrual  fluid  from  atresia.  In  the 
case  of  unmarried  women  it  should  not  be  performed  unless  specially 
necessary.  In  both  classes  of  patients  the  value  of  a  rectal  examination 
should  be  kept  in  mind.  The  vaginal  examination  should  be  made  on 
married  women  whose  symptoms  point  to  a  pelvic  cause.  Finally,  no 
woman  should  be  examined  vaginally  when  menstruating  normally, 
unless  under  exceptional  circumstances. 

Special  cases  require  consideration :  viz.,  that  of  a  mistress  who  requests  a  medical 
man  to  examine  her  servant,  who  is  suspected  of  pregnancy  ;  or  of  a  yoving  woman,  who, 
owing  to  a  malicious  report,  requests  examination  as  to  her  condition  and  a  certificate 
that  she  is  not  pregnant. 

In  the  first  case,  it  is  better  for  the  medical  man  not  to  examine  the  patient,  as  he  may 
be  liable  to  an  action  for  assault. 

In  the  second  case,  the  medical  man  should  advise  the  patient  against  being  examined. 
This  hitter  case  is  quite  different  from  that  of  an  unmarried  woman  who,  having  run  the 
risk  of  impregnation,  requests  examination  to  settle  whether  she  is  pregnant.  In  this 
instance  the  medical  man  investigates  the  case  in  the  usual  way. 

After  settling  these  preliminaries,  and  having  obtained  the  patient's 
consent  to  "  examine  "  (a  term  which  will  readily  be  understood  by  her 
as  meaning  a  vaginal  examination),  the  next  point  is  to  determine  the 
posture  the  woman  is  to  occupy  while  the  examination  is  being  made. 
Position  of  In  this  country  it  is  customary  to  place  the  patient  on  her  left  side 
for  the  vaginal  examination,  and  in  the  dorsal  posture  for  the  Bimanual. 
The  patient  lies  on  a  convenient  couch,  with  knees  well  drawn  up  and 
clothes  loose.  The  examiner  carefully  oils  or  soaps  the  index  and  middle 
finger  of  his  right  hand.  With  his  left  hand  he  clears  away  the  clothes 
from  the  hips  so  as  to  make  a  passage  for  the  examining  fingers,  which 
he  passes  onwards  till  he  reaches  the  cleft  between  the  buttocks.  He 
next  passes  them  forwards  over  the  anus,  skin  over  base  of  perineum  and 


VAGINAL   EXAMINATION.  95 

fourchette,  until  the  pulp  of  the  finger  rests  at  the  vaginal  orifice.  In 
multiparous  women,  the  lax  vaginal  orifice  is  easily  felt.  When  in 
doubt,  he  passes  his  fingers  cautiously  on  until  he  touches  the  vestibule, 
which  is  always  smooth.  Carrying  his  fingers  back,  he  will  then  reach 
the  vaginal  orifice  at  the  base  of  the  vestibule. 

The  tyro  must  be  careful  not  to  pass  his  finger  into  the  rectum  by 
mistake.  He  should  remember  that  the  vaginal  axis  passes  backwards, 
the  anal  axis  forwards  ;  that  no  force  is  required  to  pass  the  finger  into 
the  vagina  where  the  hymen  has  been  ruptured,  whereas  some  force  is 
necessary  to  overcome  the  resistance  of  the  sphincter  ani.  The  clitoris, 
lying  at  the  apex  of  the  vestibule,  should  never  be  touched,  on  vaginal 
examination. 

The  two  fingers  being  now  at  the  vaginal  orifice,  should  be  carried 
backwards  into  the  vagina  until  its  upper  limits  are  felt.  In  doing  so, 
the  following  points  should  be  noted. 

1.  State  of  Vaginal  Orifice:  patulous  or  narrow,  presence  or  absence  What  to 
of  painful  spots,  presence  or  absence  of  spasm. 

2.  Walls :  shape  and  length  ;  presence  or  absence  of  rugae  ;  moisture, 
heat,  secretion,  tumours  attached  to  them  ;  fistulse  ;  foreign  bodies,  such 
as  pessaries,  glycerine  plug,  oakum  plug. 

3.  Cervix :   direction,   size,   shape,  and   consistence.       Note  whether 
thickened,  expanded,  and  fixed  ;  drawn  to  one  or  other  side  ;  mobile  and 
not  fixed  ;  or  whether  split   and  with   cicatrices  radiating  from  it  to 
vaginal  roof. 

4.  Os  :  size,  shape,  consistence  of  lips.     Thus,  it  may  be  a  dimple,  as 
in  nulliparse  ;  transverse,  as  in  parous  women  (figs.  13  and  14);  or  the 
cervix  may  be  split  on  one  or  both  sides,  and  thus  no  os  externum  be 
present  but  the  cervical  canal  be  more  or  less  exposed  (Plate  XII.). 
Bodies  projecting  through  it  should  be  noted  :    these  may  be  polypi, 
fragments  of  abortion,  cancerous  masses,  stem  pessaries. 

5.  Posterior  fornix  is  concave  when  felt  from  below.     It  has  normally 
a  feeling  like  that  of  the  inside  of  the  angle  of  the  mouth.     Note  if  any 
lump  can  be  felt  through  it,  projecting  downwards  in  Douglas'  pouch, 
rendering  the  fornix  convex.      A  body  or  resistance  felt  through  the 
posterior  fornix  may  be  the  following : — 

(1.)  Faeces  or  tumours  in  the  rectum  ;  Bodies  felt 

(2.)  Acute  or  chronic  inflammatory  deposit  in  the  peritoneum  Ortllr?u£h 

posterior 

cellular  tissue ;  fornix. 

(3.)  Retroverted  fundus  uteri  (non-gravid  or  gravid)  ; 

(4.)  Blood  effusion ; 

(5.)  Fibroid  attached  to  posterior  wall  of  uterus ; 

(6.)  Ovary  inflamed  or  cystic ; 

(7.)  Ascitic  fluid ; 

(8.)  Extra-uterine  foetation  or  hydatid  (rare). 


96  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

Anterior  fornix. — Note  if  there  is  any  body  felt  through  it.  If  so, 
it  is  most  probably  the  fundus  uteri,  normal  or  enlarged  from  pregnancy 
or  fibroid.  There  may  be  also  inflammatory  or  blood  effusions,  or  a  tender 
ovary,  but  these  are  rare  here. 

7.  Lateral  fornices. — Note  cicatrices,  prolapsed  or  cystic  ovary,  lateri-. 
flexed  uterus,  inflammatory  or  blood  effusion  in  broad  ligament,  dilatation 
of  Fallopian  tubes,  fibroids  placed  laterally. 

The  vaginal  examination  has  now  been  completed.  The  student 
should  keep  in  mind  that  he  really  learns  very  little  from  a  vaginal 
examination,  just  as  he  can  learn  very  little  as  to  the  size  and  relation 
of  any  object  by  touching  it  with  the  fingers  on  a  but  limited  area. 
Vaginal  examination  is  thus  only  the  preliminary  to  the  bimanual  or 
abdomino-vaginal. 

BIMANUAL  (ABDOMINO-VAGINAL)  EXAMINATION. 

Bimanual.  This  method  of  examination  is  the  all  important  one  in  gynecology,  and 
is  the  one  which  the  student  and  practitioner  will  find  most  valuable,  so 
that  its  practice  should  precede  all  other  methods  of  internal  investiga- 
tion. As  the  practitioner's  experience  increases,  he  will  find  that  he  relies 
more  upon  this  and  becomes  less  dependent  on  other  means  of  examina- 
tion. 

Method  of  performing  Bimanual.  Posture  of  Patient.  The  patient 
must  now  be  placed  in  the  dorsal  posture.  The  head  and  shoulders 
should  be  supported  and  the  knees  drawn  up. 


FIG.  64. 

RIGHT  HAND  IN  BIMANUAL  EXAMINATION. 


Arrangement  of  Examiner's  hands.  The  internal  hand  (the  right)  is 
placed  as  follows:  The  fingers  (index  and  middle)  are  in  the  vagina, 
the  thumb  rests  in  the  fold  between  a  labium  majus  and  the  thigh  or 
upon  the  symphysis,  and  the  other  fingers  lie  in  the  cleft  of  the  nates 
(fig.  68),  or  flexed  on  the  palm  (fig.  65).  The  whole  hand  is  then 
rotated  backwards  so  as  to  bring  its  long  axis  as  nearly  as  possible  into 


B I  MANUAL  EXAMINATION. 


97 


the  axis  of  the  brim,  and  is  then  pushed  up  towards  the  brim  of  the 
pelvis.  Thus  the  pubic  segment,  uterus  with  annexa,  and  posterior 
vaginal  wall  are  lifted  up  towards  the  brim.  The  middle  finger  is  placed 
over  the  os  and  the  index  one  in  the  anterior  fornix,  so  that  the  uterus 
as  it  is  pushed  up  becomes  more  anteverted.  The  right  hand  while 


FIG.  65. 

BIMANUAL  EXAMINATION.     The  upper  hand  is  not  shown.     (Hart) 

examining,  therefore,  has  the  appearance  at  fig.  64.  The  external  hand  Position  of 
(the  left)  is  placed  on  the  abdominal  wall  just  above  the  pubes.  It  i 
now  steadily  depressed  until  the  abdominal  wall  below  it  is  markedly 
cupped  (figs.  65  and  66)  and  moulded  over  the  uterus  and  appendages, 
which  have  been  elevated  by  the  inner  hand.  In  this  way  the  two 
hands  estimate  the  size  and  relations  of  the  pelvic  contents,  just  as  one 
would  estimate  the  size  of  a  watch  covered  with  a  cloth.  The  student 
should  note  specially  that  the  upper  hand  should  be  steadily  and  not 
spasmodically  depressed ;  that  he  should  always  keep  the  ulnar  edge  of 
the  hand  (rather  than  the  palm)  towards  the  abdominal  surface,  so  that 
he  may  not  retrovert  the  uterus ;  and  that  he  should  palpate  all  the 
abdominal  areas  along  the  pelvic  brim  so  as  not  to  miss  anything.  His 
first  object  in  the  bimanual  examination  is  to  determine  where  the  uterus  is, 
as  this  greatly  simplifies  the  recognition  of  abnormal  products  in  the 
pelvis.  He  then  bimanually  explores  the  fornices,  moving  the  internal 
fingers  appropriately  and  noting  what  he  feels.  At  first  his  diagnosis 
should  be  simply  physical,  e.g.,  "uterus  felt  to  front  and  a  large  firm 


98   PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 


Normal 
condition 
on  Bi- 
inanual. 


lump  behind  it;"  or,  "uterus  felt  retroverted  and  a  small  moveable 
tumour  on  its  left  side." 

It  is  of  importance  that  the  student  should  know  what  a  "  normal 
bimanual "  is.  The  following  is  a  description  of  the  condition  found  in 
a  nulliparous  married  woman,  on  vaginal  and  bimanual  examination. 

"Ostium  vagina)  patulous,  and  admits  two  fingers;  vaginal  walls 
moist,  rugous,  with  no  abnormalities.  Vaginal  portion  of  cervix  normal 
in  size  (fig.  13);  os  uteri  felt  like  a  dimple,  looking  downwards  and 
backwards.  No  bodies  are  felt  through  the  lateral  and  posterior  fornices, 
which  are  concave  on  their  vaginal  aspects,  and  have  the  feeling,  on 
pressure,  of  the  angle  of  one's  mouth.  In  the  anterior  fornix  a  body  is 


nlWfac 


FIG.  66. 

ANTERIOR  ABDOMINAL  SURFACE  with  upper  hand  placed  for  Bimanual  (ad  naturam 

<™*  line  than  appears  in  the  cut,  and 
are  almos*  perpendicular  to  the  abdomi- 


towards  *he 
fingers  "°  tbat  the 


felt,  which  on  bimanual  examination  is  discovered  to  be  the  uterus  lying 
to  the  front  and  not  enlarged.  The  fundus  and  cervix  meet  at  a  very 
use  angle.  Bimanual  exploration  of  the  fornices  reveals  nothing  dis- 
tinctly palpable,  i  The  patient  complains  of  no  pain  during  the  whole 
examination." 

1  One  practised  in  the  Bimanual  can  feel  the  normal  ovaries. 


BIMANUAL   EXAMINATION. 


99 


Cases  ivhere  the  Bimamial  is  difficult.     The  student  will  soon  find  that  Difficult 
the  bimanual  can  be  performed  in  certain  cases  with  great  facility  and Bimanua1' 
accuracy,  while  in  others  it  is  exceedingly  unsatisfactory. 

The  best  case  for  a  Bimanual  is  in  a  patient  a  fortnight  or  three  weeks 
after  delivery.  The  reasons  for  this  are  evident :  The  ostium  vaginse 
and  vaginal  walls  have  been  relaxed  by  the  child's  head ;  the  pubic 
segment  has  been  drawn  up  and  its  attachments  slackened  ;  the  abdomi- 
nal walls  have  had  their  elasticity  diminished  by  the  full-time  uterus, 
and  the  uterus  itself  is  not  involuted  to  its  normal  size.  In  such  a  case, 
there  are  evidently  all  the  requisites  for  a  good  bimanual. 

Difficult  bimanual  cases  are  found  in  stout  nulliparous  women,  and 
in  cases  of  pelvic  inflammation.  In  such,  the  rectal  examination  (with 
or  without  the  use  of  the  volsella)  is  indicated. 


FIG.  67. 

DISPLACEMENT  OF  PELVIC-FLOOR  SEGMENTS  AND  ABDOMINAL  WALL  IN  BIMANUAL  (Hart). 

Students  at  first  find  the  Bimanual  unsatisfactory.  By  perseverance, 
however,  they  will  obtain  by  means  of  it  an  accuracy  in  diagnosis  which 
is  astonishing.  It  is  not  only  the  best  means  of  investigation,  but  one 
from  which  no  possible  harm  can  arise.  In  no  cases  is  it  contra-indicated 
except  those  of  advanced  cancer  or  of  acute  inflammation. 

We  have  described  the  simple  abdominal- vaginal  examination.     It  will  Varieties  of 
be  readily  understood  that  we  may  have  others,  as  follows : — 

(1.)  Recto-abdominal  (finger  in  rectum  and  left  hand  above); 


Bimanual. 


100  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

(2.)  Kecto-vagino-abdominal  (middle  finger  in  rectum,  index  finger 

in  vagina,  and  left  hand  above) ; 
(3.)  Vesico-vagino-abdominal    (middle   finger   in  vagina,   index    in 

bladder,  and  left  hand  above) ; 
Of  these  the  third  is  very  rarely  practised. 

Anatomy         Note   that   in   the   Bimanual  the  pubic   segment   with  uterus    and   its 
''"  -       annexa   are   elevated,    the   sacral  segment   shortened,   and  the   abdominal 
wall  depressed  (fig.  67). 

Before  and  after  the  Bimanual  or  other  examination,  the  examiner 
should  scrupulously  cleanse  his  hands.  There  are  no  better  substances 
for  this  than  turpentine  and  ordinary  soap.  The  odour  is  by  no  means 
disagreeable,  and  if  found  objectionable  can  be  easily  covered  by  vinegar, 
which  in  itself  is  a  good  cleanser.  The  hands  should  finally  be  rinsed 
(without  soap)  in  corrosive  sublimate,  1  in  2000  or  3000.  In  examining 
cancerous  cases,  where  the  odour  is  exceedingly  penetrating  and  per- 
sistent, it  is  a  good  plan  to  dip  the  fingers  in  turpentine  prior  to  the 
examination,  (v.  Chap.  XVI.  Antiseptics.) 


CHAPTER    IX. 

EXAMINATION  PER  RECTUM. 

LITERATURE. 

Hcyar — Die  operative  Gynakologie,  zweite  Auflage  :  Stuttgart,  1881.  Munde — Minor 
Gynecology  :  Wood  &  Co.,  New  York,  1881.  See  also  Index  of  Recent  Gynecological 
Literature  in  the  Appendix. 

THE  results  obtained  by  a  vaginal  examination  are  limited  by  the  fact  Rectal 
that  the  reflection  of  the  vaginal  walls  to  form  the  fornices,  prevents  the^*^™ 
finger  being  pushed  up  to  a  sufficient  distance.     This  defect  is  compen- 
sated for  by  the  downward  pressure  of  the  upper  hand  in  the  Bimanual ; 
but  in  cases  where  the  abdominal  walls  are  unyielding  or '  the  pubic 
segment  stiff,  due  pelvic  exploration  by  an  abdomino-vaginal  examina- 
tion alone   is   impossible.     In  such  cases,  rectal    exploration  and  the 
abdomino-rectal  or  abdomino-recto- vaginal  examination  are  invaluable  ; 
they   give    better    information    than    the    more    commonly   practised 
abdomino-vaginal. 

The  usual  methods  are  the  following  : —  Methods. 

(1.)  Simple  rectal,  abdomino-rectal,  abdomino-recto- vaginal ; 

(2.)  Passage  of  the  ivhole  hand  into  the  rectum  (Simon's  method). 

SIMPLE    RECTAL  ;    ABDOMINO-RECTAL  ;    ABDOMINO-RECTO-VAGINAL. 

Preliminaries. — The  patient  should  be  told  that  it   is  necessary  toprelimi- 
examine  the  bowel.     If  the  rectum  is  loaded  the  examination  should  be  naries- 
deferred  till  next  day,  and  the  patient  instructed  to  use  a  purgative  at 
night  and  an  enema  in  the  morning. 

The   following   points    should   be    especially   noted.     The   examiner  Manner  of 
should  thoroughly  soap  the  fingers  and  nails.     A  vaginal  examination  ^j 
may  be  made  first ;  and  then,  the  index  finger  being  kept  in  the  vagina, 
the  middle  one  is  passed  into  the  rectum  (fig.  68).     If  the  patient  is 
virginal,  and  it  is  wished  to  avoid  a  vaginal  examination,  then  the  index 
finger  alone  is  passed  into  the  rectum.     When  the  finger  or  fingers  are 
withdrawn  from  the  rectum  the  hands  should  be  at  once  cleansed  ;  there 
can  be  nothing  more  hurtful  to  a  patient's  feelings  than  the  passing  of 
the  uncleansed  fingers  from  the  rectum  into  the  vagina.     The  patient 
lies  first  on  the  left  side  and  then  on  the  back. 

The  finger  passed  into  the  rectum  goes  forwards  ;  when  passed  into  the  Anatomy 
vagina,  the  direction  is  backwards.     After  overcoming  the  resistance 
the  strong  external  sphincter  it  enters  the  rectal  ampulla  (fig.  34),  which  tion- 


What  to 
Note. 


102  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

is  often  expanded  by  flatus.  Passing  the  finger  onwards  and  to  the  left 
side,  a  confused  mass  of  tissue  is  felt  in  which  we  may  detect  the  open- 
ing betwixt  the  segments  of  the  sphincter  tertius. 

As  we  pass  the  finger  inwards  we  note  piles  (internal  and  external), 
fissures,  polypi,  ulcers,  stricture  (specific  and  malignant). 


Diagnosis 
of  Ante- 
flexion. 


FIG.  68. 
ABDOMINO-RECTO-VAOISAL  EXAMINATION.    Upper  hand  not  shown.    Xote  prolapsed  ovary. 

We  next  turn  the  pulp  of  the  examining  finger  so  that  it  lies  on  the 
anterior  rectal  wall.  Through  this  can  be  felt  the  cervix.  Note  that 
the  whole  cervix  is  felt,  which  is  much  larger  than  the  vaginal  portion 
felt  on  vaginal  examination.  Be  sure  not  to  mistake  it  for  the  body  of 
the  uterus.  If  the  uterus  lies  to  the  front,  its  forward  direction  can  be 
noted ;  if  to  the  back,  then  the  body  will  be  felt  on  passing  the  finger 
further  up.  Pushing  the  finger  well  upwards  and  passing  it  first  to  the 
right  and  then  to  the  left,  we  feel  the  ovaries  (more  distinctly  when 
enlarged)  as  small  oval  tender  bodies  (fig.  68). 

Fig.  38  shows  a  common  condition  of  the  uterus  which  is  frequently 
mistaken  for  and  treated  as  a  retroversion.  We  allude  to  the  uterus 
anteflexed  and  drawn  back  by  cellulitis  of  the  utero-sacral  ligaments. 
As  such  patients  are  usually  nulliparous  and  have  therefore  somewhat 
unyielding  abdominal  walls  which  cause  a  difficult  bimanual,  and  as  a 


RECTAL  EXAMINATION.  103 

lump  is  felt  in  the  posterior  fornix,  the  diagnosis  of  retroversion  is  often 
made.  The  rectal  examination,  however,  clears  up  the  case ;  as  the 
finger  feels  the  knee  of  the  flexion  and  the  fundus  going  forwards 
from  it. 

The  upper  hand  is  used  during  the  rectal  examination  just  as  in  the 
Bimanual,  i.e.,  the  examination  is  abdomino-recto-vaginal  or  abdomino- 
rectal.  The  simple  rectal  (with  the  finger  in  the  rectum  unaided  by 
the  other  hand)  does  not  give  much  information  as  to  the  condition  of 
the  uterus. 

Where,  from  rigidity  of  the  abdominal  walls,  it  is  difficult  to  press 
down  or  fix  the  uterus  with  the  external  hand,  this  may  be  done  with  the 
volsella  in  the  vagina.  The  use  of  the  volsella  enables  us  to  draw  the 
uterus  better  within  reach  of  the  finger  in  the  rectum.  This  examination 
per  rectum  aided  by  the  volsella  will  be  considered  in  the  next  chapter. 

Of  all  manual  examinations  of  the  pelvis,  the    abdomino-rectal    or  Value  of 
abdomino-vagino-rectal  is  the  most    thorough.     In  retroversions,  pro-5ecta! 
lapsed  ovaries,  and  pathological  auteflexion,  it  is  of  special  value.     Ation. 
patient  may  object  to  it  and  refuse  to  allow  it ;  and,  of  course,  the 
practitioner  must  keep  this  in  mind. 

SIMON'S    METHOD    OF    PASSING    THE    HAND    INTO    THE    RECTUM. 

This  consists  in  passing  the  whole  hand  through  the  sphincter  ani  Simon's 
into  the  rectum,  and  even  up  to  the  transverse  colon.     The  patient  jsMetllod- 
deeply  narcotised ;  the  hand  is  passed  cautiously  through,  by  inserting 
first  two  fingers  and  the  others  successively  until  the  entire  hand  is 
passed ;  incision  of  the  sphincter  ani  may  be  necessary.     Sometimes  an 
incurable  incontinence  of  faeces  has  resulted. 

The  unanimous  opinion  of  gynecologists  is  that  this  severe  method 
of  examination  is  unnecessary.  Careful  bimanual  examination,  aided 
when  necessary  by  anaesthetics,  gives  equally  good  results. 

For  specialists  it  is  of  use  to  know  that  valuable  results  in  minute 
precise  rectal  examination  can  be  got  by  first  injecting  air  into  the 
rectum.  The  whole  rectum  up  to  the  sigmoid  flexure  can  be  dilated, 
the  sphincters  made  out  and  the  bony  pelvic  wall  carefully  explored. 
It  is  necessary  to  add,  however,  that  this  is  an  adjunct  to  the  rectal 
method  of  examination  of  use  only  in  certain  very  rare  instances. 


CHAPTER   X. 

THE  VOLSELLA. 

LITERATURE. 

Gooddl—Some  Practical  Hints  for  the  Treatment  and  the  Prevention  of  the  Diseases  of 
Women  :  Medical  and  Surgical  Reporter,  January,  1874.  Hegar — Zur  gynakolo- 
gischen  Diagnostik  :  Die  combinirte  Untersuchung,  Volkmann's  Sammlung,  Xo.  105. 
Simpson,  A.  R. — The  Use  of  the  Volsella  in  Gynecology  :  Contributions  to  Obstetrics 
and  Gynecology,  p.  183.  The  literature  is  fully  given  in  A.  R.  Simpson's  paper. 

Volsella.  WE  have  already  seen  that  one  of  the  most  striking  anatomical  features 
and  properties  of  the  uterus  is  the  considerable  range  of  its  mobility  in 
almost  every  direction.  It  can  be  pushed  upwards  from  its  normal  posi- 
tion 11  or  2  inches,  and  is  displaceable  forwards  or  laterally  in  a  very 
marked  degree.  If  laid  hold  of  with  the  instrument  known  as  a  volsella, 
it  can  be  drawn  downwards  (by  a  force  not  exceeding  five  or  six  pounds) 
until  the  6s  externum  lies  close  to  the  vaginal  orifice.  This  procedure 
facilitates,  in  suitable  cases,  diagnosis  and  treatment  of  gynecology  so 
much  that  it  is  well  worthy  of  the  allotment  of  a  special  chapter  to  its 
discussion.  We  consider  the  following  points  : — 

1.  Description  of  instrument ; 

2.  Method  of  use ; 

3.  Mechanism  of  the  displacement  it  causes  ; 

4.  Uses ; 

5.  Centra-indications. 

Descriji-  1.  Description  of  Volsella. — At  fig.  69  is  seen  the  useful  volsella  em- 
Vo'lselln.  pl°ye(i  by  A.  R.  Simpson.  As  it  is  generally  the  anterior  lip  of  the 
cervix  that  is  laid  hold  of,  and  the  volsella  lies  along  the  straight 
anterior  vaginal  wall,  the  slight  pelvic  curve  given  to  the  blades  is 
unnecessary.  Fig.  70  shows  Hart's  volsella,  where  this  straightness  of 
the  blades  q-ud  the  vagina  is  secured,  and  the  handle  and  fingers  of  the 
gynecologist  are  kept  away  from  the  vaginal  orifice  by  the  bend  on  the 
handle.  Every  volsella  should  have  a  catch  on  it.  Sometimes  it  is 
useful  to  have  an  instrument  whose  blades  pass  over  one  another,  so  as 
to  separate,  for  instance,  the  lips  of  a  split  cervix  :  such  is  Hanks' 
instrument. 

Method  2.  Method  of  Use.     (a).    Without  previous  passage  of  Speculum. — The 

patient  is  placed  in  the  ordinary  left  lateral  posture.     Two  fingers  of  the 
right  hand  are  passed  into  the  vagina,  and  the  anterior  lip  of  the  cervix 


THE    VOLSELLA. 


105 


touched.  The  volsella,  held  in 
the  left  hand,  is  gnided  along 
between  the  index  and  middle 
exploring  fingers ;  the  anterior 
lip  of  the  cervix  is  seized  and 
drawn  down.  Rectal  examina- 
tion is  now  made.  (6.)  With 
the  Speculum.  —  For  this  see 
Chapter  XL 

3.  Mechanism  of  the  displace-  Mechanism 

ment  it  causes.  —  The   uterus   is  °ftne  Dis- 
placement 
drawn  down  so  as  to  lie  behind  caused. 

the  symphysis  pubis.  If  drawn 
down  fully,  as  it  may  be  in 
exceptional  cases,  it  has  its  long- 
axis  in  the  vagina  and  the  os 
externum  near  the  vaginal 
orifice. 

The  vaginal  walls  are  in- 
verted :  i.e.,  when  the  os  exter- 
num is  at  the  vaginal  orifice,  we 
have  a  deep  pouch  behind  and 
in  front  of  the  uterus. 

The  relations  of  the  bladder 
and  rectum  are  given  in  fig.  71. 

4.  Uses.      (a)    In   diagnosis.  Use  in 
— (1.)  The  cervix,  which  may 
seem  "  ulcerated,"  as  it  is  com- 
monly called,  is  easily  demon- 
strated  by  the  volsella   to  be 
singly  or  doubly  lacerated.     For 

this  purpose  the  anterior  and 
posterior  lips  are  laid  hold  of, 
and  when  brought  together  the 
ulceration  is  seen  to  be  due  to 
laceration  with  eversion. 

(2.)  Abdominal  tumours  can 
be  shown  to  be  connected  with 
the  uterus  or  not  as  the  case 
maybe.  If  the  patient  be  placed 
in  the  dorsal  posture  and  the 
tumour  be  laid  hold  of  by  an 
assistant,  then  when  the  uterus 
is  drawn  down,  the  tumour  can  be  felt  to  descend,  if  fixed  to  it. 


FIG.  69. 

A.  R.  SIMPSON'S  VOLSELLA  with  catch 


106  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

(3.)  To  the  examination  per  rectum  the  volsella  is  a  valuable  addi- 
tion. If  one  finger  be  placed  in  the  rectum  and  the  cervix  laid  hold 
of  with  a  volsella  and  drawn  down,  the  mobility  of  the  uterus  can 

be  estimated  ;  the  whole  posterior  uterine 
surface  may  be  palpated  for  small  fibroids. 
The  ovaries  are  made  more  accessible ; 
and  the  uterus,  especially  if  small,  can 
have  its  length  estimated  by  the  rectal 
finger. 

This  method  of  examination  of  the  uterus 
by  rectum  and  volsella,  judiciously  con- 
ducted, is  of  the  very  greatest  value. 

It  is  evident  that  it  will  also  help  one  as 
to  the  diagnosis  of  displacements  of  the 
uterus ;  but  its  value  in  this  respect  is 
somewhat  lessened  by  the  displacement  its 
use  causes.  Thus  it  makes  a  retroversion 
less  retroverted ;  an  anteflexion  less  ante- 
flexed  ;  an  anteversion  less  auteverted. 

Use  in  \\  \\  (b)  In  treatment. — In   this  the  volsella 

Treatment.  |\    |\  is    Qne    of   the    mogt    usefui    instruments 

the  gynecologist  possesses.     Thus  it  helps 
greatly  in  the  examination  of  the  aborting 
uterus ;  in  replacement  of  the  gravid  or 
non-gravid  retroverted  uterus  ;  in  insertion 
of  sponge  or  tangle  tents,  or  stem  pessa- 
..*-;.-:?     ries.     In  operations  such  as  Emmet's  for 
repair  of  the  cervix,  Sims'  division  of  the 
ft  cervix,  amputation  of  vaginal  portion  of 

HART'S  VOLSELLA.  cervix,  excision  of  the  uterus  through  the 

vagina  for  cancer,  it  is  indispensable. 

Details  of  its  uses  in  these  cases  will  be  given  under  the  special  descrip- 
tions of  the  operations ;  and  it  will  also  be  shown  in  the  Chapter  on 
Specula,  that  by  using  the  volsella  the  speculum  may  be  dispensed  with 
in  certain  cases. 

Contra-  5,  Contra-indications. — It  should  not  be  used  in  acute  peritonitic  or 

tions.         cellulitic  attacks,  in  distended  Fallopian  tubes,  in  hsematocele  or  in 
.    advanced  cancerous  disease.     No   pain   should   be  caused  by  its  use 
provided  that  only  the  vaginal  aspect  of  the  cervix  is  laid  hold  of. 

Amount  of      The  amount  of  traction  to  be  made  will  vary  with  the  necessities  of 
traction       ,,  T 

to  be  used.  tne  case-  "*  many  instances  only  a  mere  steadying  action  is  requisite  ; 
in  others  the  cervix  has  to  be  drawn  half-way  down  "the  vagina.  In 
special  cases  the  cervix  is  drawn  down  to  the  vaginal  orifice  or  beyond 
it,  as  in  amputation  of  the  cervix  or  excision  of  the  uterus. 


THE    VOLSELLA,  107 

For  simply  steadying  the  cervix,  Sims'  tenaculum  is  of  great  service 
(fig.  72).  This  is  a  form  of  sharp  hook  with  a  delicately  made  stem 
diminishing  to  the  point  which  is  set  on  the  stem  almost  at  a  right 


FIG.  71. 

MECHANISM  OF  DISPLACEMENT  OF  PELVIC-FLOOR  SEGMENTS  when  Volsella  is  used. 

angle ;  the  hook  should  be  only  very  slightly  curved  in.     In  operating 


FIG.  72. 
SIMS'  TENACULUM. 


on  carcinoma  cervicis  uteri,  the  volsella  is  occasionally  unsuitable  as  the 
tissue  is  too  friable.  A  hook  may  be  passed  into  the  cervical  canal  in 
such  cases  so  as  to  draw  down  the  uterus  sufficiently. 


CHAPTER    XI. 


Vaginal 
Specula. 


VAGINAL  SPECULA. 

LITERA  TURE. 

Barna — Diseases  of  Women  :  London,  1878.  Goodell — Lessons  in  Gynecology  :  Phila- 
delphia, 1880.  Hart—  Structural  Anatomy  :  Edin. ,  1880.  Munde — Minor  Gyneco- 
logy :  Wood  &  Co.,  New  York.  Sims,  J.  Marion — Clinical  Notes  on  Uterine  Surgery  : 
Hardwicke  &  Co.,  London,  1866.  Thomas — Diseases  of  Women:  Philadelphia,  1881. 

WE  have  already  seen  that  the  segments  of  the  pelvic  floor  are  separable 
when  a  woman  assumes  certain  postures ;  that  the  sacral  segment  can 
be  hooked  up,  and  that  by  this 'means  we  get  a  view  of  the  vaginal 
boundaries  of  these  segments  and  of  the  os  uteri.     This  is  the  natural 
method  of  opening  up  the  pelvic  floor  ;  or  the  natural  specular  method. 
Gynecologists  had  used  various  instruments  for  enabling  them  to  look 
into  the  vagina  :  but  all  of  these  proved  \insatisfactory  until  Marion  Sims, 
noting  the  natural  postural  dilatation  of  the  vagina,   introduced   his 
famous  duckbill  speculum. 
Varieties.        We  take  up  the  consideration  of  three  types  of  speculum,  viz. : — 

1.  spatular — the  duckbill  or  Sims  speculum  ; 

2.  tubular — the  Fergusson  speculum  ; 

3.  bivalve — the  Neugebauer,  Cusco  and  other  modifications. 

We  note  under  each  its  nature,  the  method  of  employing  it,  and  the 
theory  of  its  action  and  uses. 

Sims'  1.  The  SIMS  or  DUCKBILL.  SPECULUM   is  shown   at  figs.   73,   74,  and 

Speculum.  plate  vm 

Nature.  Its  Nature. — Each  instrument  in  reality  consists  of  two  specula,  which 

are  of  different  size  and  connected  by  a  handle  ;  usually,  however,  we 
speak  of  these  specula  as  the  blades  of  the  speculum.  The  real  Sims 
speculum  is  light,  has  each  blade  slightly  concave  on  its  anterior  aspect, 
and  has  the  blades  at  right  angles  to  the  intermediate  handle. 

Modifications  of  Sims'  speculum  are   numerous.     Indeed,   it   seems 
difficult  for  gynecologists  to  resist  modifying  an  instrument,  and  rare  to 

I ;../« man's,  find  them  improving  it.  The  most  widely  known  modification  is  Boze- 
man's ;  it  is  heavier  than  Sims',  has  the  blades  meeting  the  handle  sit  an 
acute  angle,  and  the  blades  more  concave  on  the  anterior  aspect.  (Fi«-s 
74  and  75.) 

One  curious  fact  about  almost  all  specula  is,  that  they  are  too  long. 


Modifica- 
tions. 


VAGINAL   SPECULA. 


109 


Sims'  blade  is  4  inches  long,  though  the  posterior  vaginal  wall  measures 
only  3~  inches.  Thus,  as  we  wish  to  expose  only  the  anterior  vaginal 
wall  and  cervix  uteri,  a  3-inch  length  of  blade  is  sufficient. 


FIG.  73. 
SIMS'  SPECULUM. 

A  modification  of  Sims'  speculum,  by  Battey  of  Georgia,  is  worthy  Battey's. 
of  note.     It  has  one  short  blade  which  meets  the  handle  at  a  more 
acute  angle.     (Fig.  76.) 


FIG.  74. 
SIMS'  SPECULUM. 


FIG.  75. 

SIMS'  SPECULUM  modified  by  BOZEMAN. 


The  method  of  employing  Sims'  speculum. — Under  this  it  is  important  Method 
to  note  : — (a)  How  to  place  the  patient,  (b)  How  to  pass  the  speculum, of  Use' 
and  (c)  How  to  hold  it  when  passed. 


FIG.  76. 

BATTEY'S  SPECULUM. 

(a).   How  to  place  the  patient. — The  patient  must  be  placed  in  the  Position  of 
Sims  or  semiprone  posture.       This  is  briefly  as  follows  :    the  patient Patient- 
lies  almost  on  the  breast ;  the  loiver  left  arm  is  over  the  edge  of  the  couch 
next  the  gynecologist ;  the  hips  are  close  to  the  edge  ;  the  knees  are  well 
drawn  up ;  and  the  upper  or  right  knee  touches  the  couch  with  its  inner 
aspect.     The  posterior  aspect  of  the  sacrum  is  therefore  oblique  to  the 
horizon.     (Plate  VII.) 


110  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

As  the  result  of  this  posture— a  modified  genupectoral  one— the  vaginal 
walls  separate  when  air  is  admitted ;  the  pubic  segment  passing  down 
with  the  viscera,  the  sacral  one  remaining  behind. 

PuMgeof  (6).  How  to  pass  the  speculum.— Choose  the  blade  which  is  of  the 
Speculum.  proper  sjze  to  pass  the  vaginal  orifice;  warm  it,  and  oil  it  with  the 
fingers  on  its  convex  aspect  only.  The  concave  surface  must  be  dry  to 
reflect  light,  and  therefore  the  speculum  should  never  be  oiled  by  dipping 
it.  Hold  it  by  the  other  blade  in  the  left  hand,  as  shown  at  fig.  77. 
Then  pass  the  index  and  middle  fingers  of  the  right  hand  into  the  vagina 
to  separate  the  labia ;  carry  in  the  speculum  between  them  ;  push  it 
onwards,  following  the  curve  of  the  posterior  vaginal  wall,  until  the  beak 
of  the  instrument  lies  in  the  posterior  fornix.  Now  draw  the  instru- 
ment back  as  a  whole,  in  a  direction  at  right  angles  to  the  posterior 
vaginal  wall ;  then  turn  the  beak  forwards,  so  as  to  bring  the  cervix  more 
into  view.  Finally,  tilt  the  blade  so  that  the  beak  lies  on  a  lower  level 
than  the  proximal  end  of  the  blade ;  this  keeps  up  the  upper  labium. 


FIG.  77. 

One  method  of  holding  the  SIMS  SPECULUM. 


How  it  is 
held. 


(c).  How  to  hold  the  speculum  when  passed. — Plate  VIII.  shows  the 
speculum  passed,  and  a  convenient  way  of  holding  it.  When  passed. 
the  cervix  may  be  drawn  down  with  a  volsella  (also  shown  in  Plate  VIII.). 
Various  attempts  have  been  made  to  add  to  the  Sims  speculum  a  means 
of  rendering  it  self-retaining ;  the  majority  of  these  are  by  no  means 
successful,  and  therefore  we  need  not  describe  what  is  seldom  used.  The 
knowledge  of  a  simple  method  of  effecting  this  in  Battey's  speculum  is  of 
use.  This  has  a  piece  of  indiarubber,  with  a  hook  at  the  end  attached 
to  the  handle,  which  can  be  fastened  in  the  pillow,  sheet,  or  patient's 
dress ;  the  cervix  is  drawn  down  with  a  volsella  held  in  the  one  hand, 
leaving  the  other  free  for  minor  manipulation. 

Action  and      Theory  of  action  and  uses  of  the  Sims  speculum. — The  Sims  speculum 

sj^  "  "'       is  based  on  the  effects  consequent  on  the  genupectoral  posture.     When 

Speculum,  the  patient  is  semiprone  and  the  vaginal  orifice  opened,  the  segments 

of  the  pelvic  floor  separate ;  and  then  the  Sims  speculum  is  a  simple 

means  of  hooking  the  sacral  segment  well  back. 

The  Sims  speculum  is,  on  the  whole,  by  far  the  most  useful  speculum. 


PLATE  VIII. 


VAGINAL  SPECULA.  Ill 

It  is  difficult  to  manipulate  at  first,  but  amply  repays  practice.  Its  in- 
vention has  been  one  of  the  greatest  strides  in  gynecology.  In  vaginal 
and  cervical  operative  surgery,  it  is  the  only  speculum  that  can  be  used. 

2.  THE  FERGUSSON  SPECULUM  is  seen  at  fig.  85.     It  is  made  in  three  Fergusson 
suitable  sizes ;  and  may  be  described  as  a  glass  tube,  with  a  proximal   pec 
trumpet  and  a  distal  bevelled  end.     It  is  made  of  glass,  silvered  on  the 
outside   and   coated   with   caoutchouc.      The   bevelling   of  the   distal 
end  makes  a  shorter  anterior  side  and  a  longer  posterior  one.      The 
maker's  name  is  usually  placed  at  the  trumpet  end,  at  the  foot  of  the 
anterior  side,  and  serves  to  indicate  that  side  when  the  speculum  is  in 
the  vagina. 


FIG.  78. 

FERGUSSON  SPECULUM. 

Mode  of  employment  of  the  Fergusson  speculum. — The  patient  lies  in  HOW  used, 
the  left  lateral  position  with  hips  raised.  Warm  the  speculum,  and  oil 
it  on  the  outside.  Take  it  by  the  trumpet  end  with  the  right  hand  and 
pass  it  into  the  vaginal  orifice  previously  opened  up  by  index  and  middle 
fingers  of  the  left ;  now  push  it  in,  short  side  to  the  front,  until  arrested. 
By  looking  along  it,  the  practitioner  can  note  if  the  cervix  is  in  view. 
It  is  generally  not  so,  but  may  be  snared  by  the  following  manoauvres  : 
carry  the  trumpet  end  well  back  towards  the  perineum,  and  then  depress 
the  distal  end  first  to  the  left  and  then  to  the  right,  finally  turning  it 
round  if  these  fail.  In  multipart  with  lax  vagina  it  is  easy  to  pass  the 
Fergusson ;  but  it  is  more  difficult  in  nulliparse. 

The  Fergusson  is  a  favourite  speculum  with  many.     It  is  useless  in  Uses, 
vaginal  and  cervical  surgery,  but  with  it  applications  to  the  cervix 
can  be  made  very  well  and  easily.     When  used  for  making  applications 
to  the  endometrium,  it  is  advisable  to  pull  the  cervix  well  down  with  a 


112  PHYSICAL  EXAMINATION  OF  THE  PELVIC  ORGANS. 

volaella   after  the  speculum    is  passed,   and  to   use   a   straight    sound 
covered  with  cotton  wool. 

3.  Of  bivalve  specula  there  are  various  forms :  the  Neugebauer  with 
its  modification— the  Crescent  Speculum  of  Barnes ;  the  Cusco,  which 
is  often  called  the  Bivalve  Speculum ;  and  other  varieties. 

Neuge-  The  NEUGEBAUER  is  like  a  Sims   speculum  divided  transversely  at 

the  middle  of  the  handle  (fig.  79).     It  is  also  made  in  suitable  sizes. 


FIG.  80. 

Cross  section 
showing  i-elation 
of  blades  ;  the 
upper  is  posterior. 


FIG.  79. 

NEUGEBAUER'S  SPECULUM  when  passed. 

How  used.  Mode  of  employment. — Warm  and  oil  two  blades.  Introduce  one  blade 
(the  broader  one)  with  its  convexity  touching  the  posterior  vaginal  wall. 
Then  introduce  the  other  with  its  convexity  touching  the  anterior  vaginal 
wall  and  so  that  its  edges  fit  within  the  edges  of  the  posterior  vaginal 
wall  blade  (fig.  80).  The  beak  of  the  posterior  blade  is  thus  in  the 
posterior  fornix  ;  that  of  the  anterior  blade  in  the  anterior  fornix.  From 
their  contact  a  leverage  is  obtained  on  approximating  the  handles,  by 
which  traction  is  made  on  the  fornices,  and  the  cervical  canal  more  or 
less  everted. 

Km  ii.->'  Fig.  81  shows  a  useful  modification  of  this  by  Barnes,  known  as  the 

SSm.  Crescent  speculum. 

The  Neugebauer  and  Crescent  specula  are  useful  in  making  cervical 

and  endometric  applications,  and  are  better  specula  than  the  Fergusson. 

The  Cusco  or  BIVALVE  SPECULUM  is  shown  at  fig.  82.     It  is  composed 

of  two  blades  jointed  on  to  one  another  at  their  bases.     The  blades  are 


VAGINAL  SPECULA.  113 

opened  to  the  desired  distance  by  pressure  on  the  thumb-piece,  and 
kept  open  by  a  screw.  It  is  introduced  with  its  blades  right  and  left, 
and  then  turned  so  that  they  lie  anterior  and  posterior,  that  with  the 


FIG.  81. 
BAENES'  CRESCENT  SPECULUM. 


screw  being  posterior.     It  is  then  pushed  onwards,  and  the  blades  opened 
and  fixed  by  the  screw.     Care  should  be  taken  not  to  catch  any  of  the 


FIG.  82. 

Cusco's  SPECULUM. 

hair  in  the  screw ;   and,  in  withdrawing  it,  not  to  pinch  up  the  vaginal 

walls. 

H 


114     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

The  Cusco  speculum  is  self-retaining  and  useful  in  cervical  and  endo 
metric  applications. 

W.  L.  Reid  of  Glasgow  has  introduced  another  variety  of  bivalve 
speculum  which  he  has  found  useful.  In  it  the  blades  are  separable  and 
move  on  parallel  bars. 

If  the  patient  be  placed  in  the  genupectoral  or  semiprone  posture,  the 
posterior  vaginal  wall  hooked  back  with  the  fingers  and  the  cervix  drawn 
down  with  a  volsella,  a  useful  view  can  be  obtained  without  the  aid  of  any 
speculum. 

USES   AND    COMPARATIVE    VALUE    OF   THE    VARIOUS    SPECULA. 

The  Sims  is  undoubtedly  the  best  and  most  scientific  speculum  we 
possess.  When  properly  used  and  aided  by  the  volsella  or  tenaculum,  it 
leaves  nothing  to  be  desired.  For  operative  cases  its  use  is  imperative ; 
and  it  is  the  only  speculum  which  does  not  distort  the  split  cervix.  It 
is  objected  by  some — on  insufficient  grounds — that  it  is  difficult  to  mani- 
pulate, requires  a  skilled  assistant,  and  exposes  the  patient  unduly. 

The  Fergusson  is  easily  passed,  involves  only  slight  exposure,  and  is 
good  in  very  minor  gynecology.  It  gives  only  a  limited  view  of  the 
vaginal  walls.  The  student  should  note  that  it  brings  the  flaps  of  a 
split  cervix  together  and  somewhat  conceals  the  lesion. 

The  Neugebauer,  on  the  other  hand,  opens  up  a  cervical  split,  and 
may  do  this  so  effectually  as  to  give  the  impression  that  there  is  none. 
The  Fergusson  and  Cusco  are  self -retaining. 


CHAPTER  XII. 

THE  UTERINE    SOUND. 

LITERA  TURE. 

Simpson,  A.  R. — The  Uterine  Sound  :  Ed.  Med.  Journal,  1882.  Simpson,  Sir  J.  Y. — 
Memoir  on  the  Uterine  Sound,  Selected  Obst.  Works :  A.  &  C.  Black,  Edinburgh, 
1871. — See  Munde's  Minor  Gynecology  and  Thomas  as  to  Huguier  &  Lair. 

WE  shall  consider  this  important  gynecological  instrument  as  follows  : —  Uterine 

1.  Its  nature ; 

2.  Preliminaries  to  its  use,  contra-indications ; 

3.  Method  of  use,  difficult  cases ; 

4.  Employment  for  diagnosis  and  treatment ; 

5.  Dangers  attending  its  use  ; 

6.  Relation  to  bimanual  and  rectal  examination. 

NATURE. 

The  sound  of  Sir  James  Simpson  is  not  only  the  classical  instrument,  Nature, 
but,  taken  all  in  all,  is  probably  the  best.     We  describe  it,  therefore,  as 
a  type  of  the  instrument,  and  then  consider  its  modifications. 


FIG.  83. 
SIR  J.  Y.  SIMPSON'S  SOUND. 

Simpson's  sound  is  a  rod  of  flexible  metal  12  inches  long,  specially 
graduated,  and  provided  with  a  suitable  handle  (fig.  83).  It  is  made  of 
copper,  nickel-plated ;  this  is  sufficiently  pliable  to  be  moulded,  and  yet 
sufficiently  stiff  to  retain  any  special  shape  given  to  it.  Instrument- 
makers  often  make  this  sound  too  unyielding.  It  should  be  always 
pliable  enough  to  be  bent  with  two  fingers. 

The  handle  has  the  shape  shown  at  fig.  83.  Note  that  it  is  roughened 
on  the  same  side  as  that  towards  which  the  point  of  the  instrument  lies. 
Consequently,  when  the  sound  is  in  the  uterus,  we  can  tell  the  direction 
of  the  point  by  noting  this  roughness  on  the  handle. 

The  graduation  is  important.     2^  inches  from  the  point  is  a  rounded 


116     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

knob :  this  is  the  length  of  the  fully-developed  unimpregnated  uterine 
cavity.  Other  markings  are  3^  inches,  4^  inches,  5|  inches,  and  so  on 
up  to  8i  inches.  The  notch,  11  inches  from  the  point,  is  of  little  use 
and  weakens  the  instrument. 

The  modifications  of  this  instrument  are  numerous.  The  changes  are 
chiefly  in  its  flexibility,  lightness,  and  in  the  use  of  another  material. 

A.  R.  Simpson  has  modified  the  instrument  by  making  it  shorter, 
abolishing  the  li  inch  notch,  and  squaring  the  handle  (fig.  91)  : 
this  gives  a  very  handy  and  useful  instrument.  Sims,  Emmett,  and 
Thomas  have  each  a  special  sound.  Thomas'  is  made  of  hard  rubber  or 
whalebone,  and  he  claims  that  it  is  specially  useful  in  the  case  of  sub- 
mucous  fibroids.  Other  modifications  are-  by  Matthews  Duncan, 
Protheroe  Smith,  Aveling,  Jennison  and  Hanks. 


FIG.  84. 
A.  R.  SIMPSON'S  SOUND. 


PRELIMINARIES    TO    ITS    USE  :     CONTRA-INDICATIONS. 

No  instrument  should  have  the  preliminaries  to  its  use  more  carefully 
u"1.63        considered.     The  rash  and  careless  use  of  the  sound  may  do  immense 
mischief  to  the  patient     Note,  then,  when  not  to  use  it. 

(1.)  The  sound  is  not  to  be  passed  during  an  ordinary  menstrual 

period. 
(2.)  It  is  not  to  be  passed  in  an  acute  inflammatory  attack  of  uterus, 

ovaries,  pelvic  peritoneum,  or  connective  tissue. 
(3.)  It  is  not  to  be  passed  in  cases  of  cancer  of  the  cervix  or  body  of 

the  uterus. 

(4.)  It  is  not  to  be  passed  if  the  patient  has  missed  a  menstrual 
period.     This  is  a  safe  rule,  but  admits  of  limitation,  as  we 
shall  see  afterwards. 
Before  using  it,  attend  to  the  following  points. 

(1.)  Ascertain  that  the  patient  has  not  missed  a  period. 


UTERINE  SOUND.  117 

(2.)  Do  the  bimanual  carefully.     If  in  doubt,  use  the  rectal  exami- 
nation aided  by  the  volsella. 
(3.)  Place  the  patient  in  the  left  lateral  posture. 
(4.)  Give  the  sound  the  curve  you  find  the  uterus  to  have. 

METHOD    OP   USE. 

After  the  preliminaries  mentioned  above,  take  the  sound  in  the  hand,  Method 
dip  its  first  3  inches  in  an  antiseptic  solution.     Pass  the  index  finger  of0 


FIG.  85. 
FIRST  STAGE  OF  PASSING  THE  SOUND. 

the  right  hand  into  the  vagina  and  touch  the  anterior  lip  of  the  cervix, 
i.e.,  in  front  of  the  os.  Guide  the  sound  along  the  vaginal  finger  and 
make  the  point  enter  the  os  uteri  (fig.  85).  Pass  it  in  for  an  inch  or  so, 
to  fix  it. 

If  the  uterus  be  retroverted  then  carry  the  handle  towards  the  symphy- When 
sis,  when  the  point  of  the  instrument  will  glide  into  the  uterine  cavity  troverted. 
until  arrested  by  the  fundus  (fig.  86).     No  force  is  needed.     If  force 
seems  necessary,  the  instrument  should  be  withdrawn  and  a  more  careful 
Bimanual  performed. 


118     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 


Whan 

Uterus  to 
front. 


If  the  uterus  lie  to  the  front,  the  procedure  is  different.  Pass  the  sound 
as  already  described  until  it  has  entered  the  cervix  for  an  inch  or  so 
(fig.  85).  Note  now  that  the  point  of  the  sound  looks  back,  whereas  the 
fundus  lies  to  the  front.  Clearly,  we  must  make  the  point  look  to  the 
front.  This  is  done  by  turning  the  handle  so  that  its  roughened  surface 
looks  to  the  front.  To  do  this  we  do  not  twist  round  the  handle  on  its 
long  axis,  but  make  it  sweep  round  the  arc  of  a  wide  semi-circle  as  in 
fig.  87.  The  point,  during  this  manoeuvre,  remains  fixed  or  nearly  so. 


FIG.  86. 
SECOND  STAGE  OF  PASSING  THE  SOUND  when  UTERUS  is  Retroverted. 

Now  carry  the  handle  back  to  the  perineum  when  the  point  glides  into 
the  cavity  (fig.  88). 

Another  way  of  passing  the  sound,  when  the  uterus  lies  to  the  front, 

5  follows.     Place  the  patient  well  across  the  bed.     Do  Bimanual  and 

curve  sound  appropriately.     Take  the  sound  in  the  right  hand.     Pass 

two  fingers  of  the  left  hand,  palmar  surface  forward,  into  the  vagina,  and 

ich  the  posterior  lip  of  the  cervix.     Carry  the  sound,  point  looking 


UTERINE  SOUND. 


119 


forwards,  into  the  vagina ;  make  it  enter  the  os,  and  then  carry  the  handle 
towards  the  perineum,  when  the   point  will  glide  on       This  method 


(a.)  FIG.  87.  (6.) 

(a.)  Proper  method  of  TURNING  THE  SOUND,  contrasted  with  improper  method  (6.). 

avoids  the  sweeping  round  of  the  handle,  and  is  useful  if  the  uterus  is 
very  much  ante  verted. 


FIG. 

SECOND  STAGE  OF  PASSING  THE  SOUND  when  UTERUS  is  to  the  Front. 

The  sound  may  be  passed  after  the  uterus  is  drawn  down  with  a 
volsella,  or  after  the  Sims  speculum  has  been  introduced. 

Difficult  Cases. — These  are  chiefly  found  in  markedly  anteflexed  uteri.  Difficult 
The  sound  passes  in  so  far  (fig.  89),  but  when  turned  has  its  point  Iook-g0und. 


120    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

ing  too  directly  upwards.  In  such  cases  first  draw  the  cervix  down  with 
a  volsella,  now  pass  the  sound,  and  should  it  still  stop  at  the  flexion 
make  pressure  with  a  finger  in  the  anterior  fornix  to  push  up  the  fundus. 


FIG.  89. 

SOUND  ARRESTED  (before  Rotation)  in  a  case  of  Anteflexion. 

Then  get  an  assistant  to  carry  the  handle  of  the  sound  towards  the 
perineum. 

When  the  uterine  cavity  is  tortuous  as  in  submucous  fibroids  a  gum- 
elastic  bougie — No.  10 — may  be  used  to  ascertain  its  length.  Thomas', 
Jennison's,  or  Emmet's  sound  is  specially  useful  here. 


UTERINE  SOUND.  121 

EMPLOYMENT    OP    THE    SOUND    FOR    DIAGNOSIS    AND    TREATMENT. 

(A)  DIAGNOSIS. 

(1.)  Length  of  uterine  cavity.     This  varies  in  different  pathological Use  of 

Sound  in 

conditions.     Thus  the  cavity  is  Diagnosis. 

(a)  lessened  in  Superinvolution  of  uterus, 
Atrophic  uteri ; 

N.B. — The  sound  easily  perforates  the  thin  wall  of  the  super- 
involuted  uterus  ;  this  does  no  harm.  It  may  also  pass 
along  the  Fallopian  tube. 

(6)  increased  in  Subinvolution  of  uterus, 
Hypertrophy  of  uterus, 
Cervical  hypertrophy, 
Endometritis, 
Submucous  fibroids, 
Interstitial  fibroids, 
Small  uterine  polypi, 
Prolapsus  uteri. 

(2.)  Direction  of  uterine  axis  ;  whether  retroverted,  anteverted,  lateri- 
verted. 

(3.)  Relation  of  axis  of  uterine  body  to  that  of  cervix ;  whether  we 
have  anteflexion  or  retroflexion. 

(4.)  Stenosis  and  atresia  at  os  internum  and  os  externum  ;  tenderness  of 
fundus,  as  in  endometritis. 

(5.)  Mobility  of  uterus.  This  should  be  ascertained  in  the  following- 
way.  Pass  the  sound  as  already  described.  Make  the  patient  turn  on 
her  back,  and  then  place  two  fingers  in  the  vagina,  palmar  surface  up- 
wards and  touching  the  posterior  lip  of  the  cervix.  The  sound  lies  on 
the  palm  of  the  hand,  is  steadied  with  the  thumb,  and  can  be  used  to 
move  the  uterus  gently  about  as  desired. 

(6.)  Rough  condition  of  endometrium  ;  often  associated  with  bleeding 
when  sound  is  passed. 

(7.)  Differential  diagnosis  between  uterine  polypi  projecting  into  vagina, 
and  inverted  uterus,  etc. — When  we  have  a  polypus  to  deal  with,  the 
sound  passes  in  through  the  cervix  for  more  than  the  usual  distance 
because  the  uterine  cavity  is  enlarged.  In  inversion,  it  passes  for  only 
a  short  distance  into  the  cervix  and  is  then  stopped  by  its  reflexion. 
Sometimes,  however,  the  neck  of  the  polypus  is  adherent  all  round  to 
the  cervical  canal,  thus  simulating  inversion  :  and  in  some  very  rare  cases 
the  mucous  membrane  of  the  uterus  becomes  separated  and  expelled  from 
the  uterine  cavity,  simulating  inversion  of  the  whole  uterus  owing  to  the 
separation  stopping  at  the  os  internum.  It  is  evident  that  in  these  last 
two  cases  the  Bimanual  clears  up  the  diagnosis,  the  upper  hand  feeling 


122    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

the  body  of  the  uterus  in  its  normal  position  in  both  of  them.     The 
sound  is  only  confirmatory  of  the  Bimanual. 

(B)  TREATMENT. 

Use  of  _  (1.)  Rectification  of  abnormal  angular  relation  between  the  uterine  body 

Treatment. anc^  cervix  (anteflexion,   retroflexion) ;  dilatation  of  uterine  canal  as  a 
whole,  or  of  stricture  at  os  intemum. 

(2.)  Replacing  of  retroverted  unfixed  uterus, 

(3.)  Application   of  acids   to  endometrium  on   the  sound  covered  with 
cotton  wool. 


FIG.  90. 
SOUND  combined  with  BIHANCAL  Examination  (A.  R.  Simpson). 


DANGERS   ATTENDING   ITS    USE. 

Dangersof      The  great  dangers  to  the  patient  from  the  passage  of  the  uterine  sound 
bortion,  and  abrasion  of  the  mucous  membrane  with  absorption  of 
septic  matter  and  resulting  pelvic  cellulitis  or  peritonitis. 


UTERINE  SOUND.  123 

The  former  untoward  result  must  be  very  carefully  guarded  against. 
One  valuable  caution  is  never  to  omit  the  question  as  to  the  menstruation, 
and  to  ask  if  it  was  the  usual  amount.  Some  women  have  a  slight 
discharge  of  blood  at  the  first  period  after  they  conceive,  some  even 
menstruate  during  the  whole  period  of  uterogestation.  The  best  safe- 
guard is  the  careful  performance  of  the  Bimanual.  This  soon  teaches  the 
practitioner  to  know  whether  he  has  an  unimpregnated  uterus  between 
his  hands,  or  one  at  the  second  or  third  month  of  gestation.  Special  care 
should  be  taken  when  the  uterus  is  retroverted :  it  may  be  also  gravid  ; 
and  the  pregnancy  may,  by  causing  pressure,  have  induced  the  patient 
to  consult  a  medical  man.  As  the  Bimanual  is  often  difficult,  an  unwary 
use  of  the  sound  may  make  the  diagnosis  disagreeably  evident. 

The  means  to  avoid  setting  up  any  inflammatory  disturbance  are — to 
perform  the  Bimanual  carefully,  to  curve  and  oil  the  sound  properly,  and 
to  pass  it  gently. 

SOUND    COMBINED    WITH    BIMANUAL. 

The  importance  of  this  method  of  examination  has  been  recently  use  of 
pointed  out  by  A.  R  Simpson.     For  its  performance  the  short  sound  Sound  m 
with  the  square  handle  (fig.  84)  is  necessary.     It  is  of  such  a  length  that, 
when  the  middle  finger  is  at  the  knob,  the  flat  surface  of  the  handle 
rests  on  the  ball  of  the  little  finger,  against  which  it  is  steadied  by  the 
flexed  little  and  ring  fingers. 

The  sound  is  introduced  into  the  uterus  in  the  ordinary  way.  The 
fingers  are  passed  into  the  vagina  as  for  a  vaginal  examination,  and  the 
sound  grasped  as  in  fig.  84.  Or  the  sound  may  be  steadied  with  the 
middle  finger  while  the  index  is  used  to  feel  the  uterus  through  the 
anterior  fornix  (fig.  90).  The  external  hand  is  placed  as  in  the 
Bimanual. 

This  method  is  specially  useful  (a)  when  the  uterus  is  flaccid  ;  the 
sound  stiffens  it,  and  enables  the  external  hand  to  define  it :  (b)  when, 
from  the  presence  of  small  fibroids  or  pelvic  deposits,  there  is  doubt  as 
to  what  is  the  fundus  uteri ;  the  sound  felt  by  the  external  hand  in  the 
uterus,  indicates  the  fundus. 

RELATION    OF    SOUND    TO    BIMANUAL   AND    RECTAL   EXAMINATION. 

Before  Sir  James  Simpson  introduced  the  use  of  the  sound,  gyneco-  Relation  of 

logical  examination  was  confined  to  the  exploration  of  the  vagina  and  Sound  to 

Bimanual 
cervix.  and  Rectal 

Simpson  gave  an  immense  impulse  to  Gynecology,  by  placing  in  the 
hands  of  gynecologists  an  instrument  which  explored  the  uterine  cavity 
above  the  cervix,  and  enabling  them  to  obtain  a  perfection  of  diagnosis 
before  undreamed  of;  thus  gynecological  examination  came  to  consist 
of  a  vaginal  examination,  and  then  a  passage  of  the  sound,  due  attention 


124     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

being  given  to  the  non-existence  of  pregnancy.  He  recommended, 
further,  the  elevation  of  the  uterus  with  the  sound,  and  its  definition 
with  the  upper  hand. 

The  next  step  in  Gynecology  was  the  use  of  the  two  hands — the 
bimanual  and  rectal  examinations — which  in  the  last  twenty  years  has 
developed  immensely.  Consequently,  the  use  of  the  sound  has  become 
more  limited.  The  teaching  in  this  chapter  has  been  based  on  a  recog- 
nition of  this  fact,  inasmuch  as  the  use  of  the  sound  is  recommended 
only  after  the  bimanual,  rectal,  and  volsellar  examinations  have  been 
carefully  employed. 


CHAPTER  XIII. 

TENTS   AND    OTHER   UTERINE    DILATORS. 

LITERATURE. 

Hegar  und  Kaltcribach. — Die  Operative  Gynakologie  :  Stuttgart,  1881.  Landau — Ueber 
Erweiterungsmittel  der  Gebarmutter  :  Volkmann's  Sammlung,  No.  187.  Lewers — 
On  Rapid  Dilatation  of  the  Cervix  Uteri:  Lancet,  1887,  II.,  p.  507.  Mundt— 
Minor  Gynecology  :  New  York,  1881.  Simpson,  J.  Y. — Selected  Obst.  "Works,  Vol. 
I.  :  Edinr.  1871.  Sims,  J.  M. — Uterine  Surgery  :  London,  1867.  See  also  Index 
of  Recent  Gynecological  Literature  in  Appendix. 

HITHERTO  we  have  considered  only  the  means  which  have  placed  the  Uterine 
vagina  and  cervix  within  range  of  digital  examination.     In  this  section    x a  ors' 
we  take  up  the  methods  by  which  we  get  digital  examination  of  the 
uterine  cavity — methods  of  the  highest  practical  value,  which,  like  the 
sound,  we  owe  to  the  genius  of  Sir  James  Simpson. 

We  therefore  consider  the  following  methods  of  dilating  the  cervical 
canal : — 

I.  Slow  dilatation  with  Sponge  Tents,  Tangle  Tents,  Tupelo  Tents ; 

II.  Rapid  dilatation  with  graduated  hard-rubber  Dilators — Tait's, 

Hanks',  and  Hegar' s  ; 

III.  Dilatation  by  incision  and  screw  Dilators  (v.  Chap.  XXVI.). 

DILATATION  BY  SPONGE,  TANGLE,  AND  TUPELO  TENTS. 

1.  Material. — The  sponge  tent  is  a  cone  of  good,  unbroken,  thoroughly  Sponge- 
dried  sponge,  impregnated  with  some  antiseptic,  and  then  firmly  com-  material, 
pressed  into  small  transverse  bulk,  its  original  length  being  preserved. 
When  thus  prepared  and  placed  under  conditions  where  it  can  absorb 
moisture,  it  swells  up  ;    and  in  thus   expanding  dilates   any  dilatable 
structure  which  may  grasp  it. 

Good  sponge  tents  of  various  sizes  may  be  had  from  all  chemists.  In 
order  to  prevent  the  antiseptic  from  volatilizing,  the  sponge  tents  are 
covered  with  grease.  They  are  provided  with  a  tape  at  the  base  to  aid 
their  extraction  from  the  cervix  after  use. 

Tents  are  also  made  from  the  ordinary  sea-tangle  (laminaria  digitata) 
(fig.  91),  and  from  tupelo  wood  (nyssa  aquatilis).  It  is  alleged  that  the 
tupelo  expands  more  rapidly  than  either  tangle  or  sponge.  Fig.  92 


Uses  of 
Tents. 


126    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

shows  its  power  in  this  respect     Tangle  tents  may  be  had  hollow ;  this 
facilitates   the   imbibition   of  moisture   but  weakens   their   expanding 

power. 

2    Purposes  for  which  used. 

(1.)  To  restrain  haemorrhage  in  cases  of  abortion,  and  at  the  same 
time  dilate  the  cervix  for  further  interference. 

(2.)  To  dilate  the  cervix  and  uterine  cavity,  and  enable  the  prac- 


Scope  of 
Tents. 


FIG.  91. 

Shows  on  the  left  a  straight  and  a  curved  tangle  tent,  and  on  the  right  these  tents  after  expansion. 
Note  how  one  has  been  gripped  by  the  os  internum  (Munde). 

titioner  to  ascertain  and  remove  the  cause  of  pathological  uterine 
haemorrhage,  whether  due  to  endometritis,  sarcomata,  polypi,  or  incom- 
plete abortion. 

(3.)  To  correct  pathological  flexions  of  the  uterus,  or  to  dilate 
a  stenosed  cervix.  Their  use  for  this  is  not  only  unnecessary  but 
dangerous. 

Tangle  tents  have  the  same  scope  as  sponge  tents.  They  do  not, 
however,  expand  so  well  and  thoroughly.  Their  special  advantages 
are  due  to  their  smaller  size,  and  the  fact  that  several  may  be 
passed  at  the  same  time  into  the  cervix.  They  are  specially  useful, 


TENTS. 


127 


therefore,  in  cases  of  narrow  cervix  and  flexions.  Tupelo  tents  are 
very  good ;  they  are  easily  passed  and,  from  their  rapid  expansion, 
preferable  to  sponge  tents. 


FIG.  92. 

DIAGRAM  to  show  relations  between  size  of  Tupelo  Tent,  before  and  after  expansion.     The  dotted 
outside  line  indicates  the  size  of  the  tent  after  expansion  (  Munde). 

3.  Preliminaries  to  and  Method  of  use. —  Tents  should  not  be  passed  Prelimi- 
during  an  ordinary  menstrual  period,  although  they  often  require  to  be  Mode  of 
used  when  pathological  bleeding  is  going  on.  They  should  always  be Use- 


FIG.  93. 

EXPANDED  TUPELO  TENT  with  constriction  at  os  internum  (Munde). 

passed  at  the  patient's  own  house ;  and  she  should  be  kept  strictly  in 
bed  during  their  use,  and  for  some  time  after.  Before  their  use,  the 
vagina  should  be  thoroughly  washed  out  with  warm  carbolic  lotion  (1-40), 
or  with  corrosive  sublimate  (1-2000).  Schultze,  in  passing  tangle  tents 


128    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

for  flexions,  first  ascertains  the  uterine  curve  with  the  sound ;  if  blood 
follows  its  use,  he  postpones  the  introduction  of  the  tent  for  forty-eight 
hours,  in  the  meantime  applying  pure  carbolic  acid  to  the  endometrmm. 
Before  using  the  sponge  tent,  it  is  advisable  to  remove  most  of  the  gre 

covering  it 

Sponge  tents  may  be  used  in  various  ways. 

How  (1  )  The  patient  is  placed  in  the  genufacial,  or  better,  in  the  semi- 

pa8Bed<  prone  posture.  Sims'  speculum  is  passed,  the  anterior  lip  of  the  cervix 
laid  hold  of  with  a  volsella  and  drawn  down.  The  sponge  or  tangle 
tent,  held  in  forceps,  can  then  be  passed  into  the  cervix  (fig.  95). 

(2.)  The  tent  is  fixed  on  the  spike  of  an  appropriate  instrument,  and 


FIG.  94. 
SPONGE  TENT  POLYPUS  OF  SIR  JAMES  SIMPSON.  (\) 

Drawing  of  the  uterus  which  contained  a  polypus — obtained  from  a  patient  of  Sir 
James  Simpson's,  who  died  from  the  haemorrhage  it  caused.  It  was  this  preparation 
which  suggested  to  him  the  sponge  tent. 

is  then  passed  like  the  uterine  sound;  i.e.,  with  the  patient  placed  in 
the  left  lateral  position,  the  index  and  middle  fingers  carried  into  the 
vagina  and  placed  on  the  anterior  lip  of  the  cervix.  The  tent,  fixed  on 
the  spike,  is  passed  along  these  fingers  and  its  point  made  to  enter  the 
cervix.  The  handle  is  then  rotated  and  carried  to  the  perineum. 

(3.)  The  patient  is  placed  on  her  left  side  and  athwart  the  bed.  Pass 
the  volsella,  draw  the  anterior  lip  of  the  cervix  down.  The  volsella  is 
not  always  needed.  Place  the  tent  between  the  index  and  middle  fingers 
of  the  left  hand  with  the  thumb  at  the  base,  carry  these  fingers  into  the 
vagina  with  their  dorsum  on  the  posterior  vaginal  wall,  make  the  point 
of  the  tent  enter  the  cervix  and  push  it  on  with  the  thumb. 


TENTS. 


129 


Another  way  is  to  use  the  volsella  as  above  described,  but  to  fasten 
it  to  the  bed.  Then  pass  Sims'  speculum  holding  it  with  the  left  hand, 
so  that  the  tent  held  in  the  right  hand  can  be  passed  into  the  cervix 
without  difficulty. 

Occasionally,  difficulty  is  experienced  in  passing  a  tent,  owing  to 
marked  anteversion  of  the  uterus.  If  the  cervix  be  drawn  down  with 
a  volsella,  the  difficulty  may  be  overcome ;  or  it  may  be  necessary  to 
partially  retrovert  the  uterus  bimanually  prior  to  passing  the  tent. 


FIG.  95. 

SIMS'  DIAGRAM  ILLUSTRATING  PASSAGE  OF  TANGLE  TENT.     Patient  is  semiprone,  Sims'  speculum 
passed,  and  cervix  steadied  with  tenaculum.     The  tent  is  passed  with  forceps. 

Tangle  and  Tupelo  Tents. — The  same  instructions  as  for  sponge  tents  Moulding 
hold  good.     Tangle  tents,  however,  when  used  to  correct  flexions  must^a  Tupelo 
first  be   moulded  as  follows  : — Ascertain  the  curve  of  the  uterus  byTents- 
bimanual  and  sound,  select  a  suitable  tent  and  dip  it  for  a  few  seconds 
in  boiling  water,  then  mould  it  to  uterine  curve  and  pass  it  as  already 
explained. 

Tents  require  to  be  left  in  the  cervix  for  a  period  varying  from  12  to 
15  hours,  and  the  vagina  should  be  frequently  douched  with  carbolic 
lotion  during  this  time.  At  the  end  of  this  period  the  tent  should  be 
removed.  During  the  removal  no  great  force  should  be  used.  Some- 
times the  removal  is  difficult  owing  to  constriction  by  the  os  internum 
or  to  irregularities  in  the  mucous  membrane. 

The  cervix  is  generally  then  sufficiently  dilated  to  admit  of  digital 
examination  of  the  endometrium. 

4.   Dangers  of  Sponge  and  Tangle  Tents  and  contra-indications. — The  Dangers 
practitioner  must  keep  prominently  before  him  that  the  use  of  a  tent  Qonfra_ 

may  prove  by  no  means  a  harmless  measure.     Cases  of  death  from  septi-  indica- 

tions. 


130     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

cjemia  after  the  careful  and  proper  use  of  one  tent  have  occurred.  The 
patient  runs  a  risk  proportionate  to  the  number  used  ;  and,  therefore,  it 
is  not  advisable  to  use  more  than  two  consecutively  unless  under  special 
circumstances.  They  are  not  to  be  used  if  acute  or  sub-acute  pelvic 
inflammation,  pyosalpinx,  ovaritis  (acute  or  chronic),  carcinoma  cervicis, 
or  pelvic  haematocele  be  present. 

The  reason  why  sponge  tents  may  prove  dangerous  is  only  too  ap- 
parent. The  uterine  mucous  membrane  is  a  lymphatic  surface  absorbing 
most  rapidly.  We  cannot  insert  sponge  tents  with  Listerian  precau- 
tions; and,  in  addition,  we  have  the  expanding  pressure  of  the  tent 
forcing  septic  matter  into  the  mucous  membrane. 


FIG.  96. 

TAIT'S  DILATORS. 

To  sum  up  briefly,  tents  are  highly  useful  in  necessary  cases — no 
means  at  the  disposal  of  the  gynecologist  gives  him  in  proper  cases  such 
valuable  help ;  but  he  should  not  forget  the  risks  occasionally  arising 
from  their  use — risks  which  should  make  him  cautious  but  not  timid. 

Hard  RAPID  DILATATION  BY  GRADUATED  HARD-RUBBER  DILATORS — 

TAIT'S,  HANKS',  HEGAR'S. 

Dilators — 

Taitx  The  statement  already  made  as  to  the  dangers  attending  the  use  of 

slowly  expanding  tents  would  lead  one  to  expect  that  attempts  at  rapid 
dilatation  have  been  made.  For  this  purpose,  graduated  vulcanite  dila- 
tors have  been  employed  by  Tait,  Hanks,  and  Hegar. 

Taifs  dilators  consist  of  graduated  vulcanite  cones  (fig.  96)  which 
can  be  screwed  on  to  a  suitable  handle.  The  proximal  end  of  the  handle 
is  perforated  for  elastic  bands  which,  passing  in  front  and  behind,  are 
attached  to  a  suitable  belt  round  the  patient's  waist.  Thus  the  elas- 
ticity of  the  bands  causes  the  cone  gradually  to  pass  up  into  the 
cervix,  dilating  it  as  it  goes.  By  this  apparatus,  Tait  claims  to  avoid 
septic  infection  and  to  dilate  rapidly.  The  obvious  objection  is  the 
amount  of  watching  it  entails  and  the  absence  of  the  pelvic  curve  on 
the  handle. 

In  cases  of  abortion  where  the  cervix  is  dilatable,  Hanks'  dilators 
seem  serviceable.  They  have  the  oval  shape  seen  at  fig.  97,  are  gradu- 
ated in  size  and  screw  on  to  the  sigmoid  handle.  They  can  be  used 
manually  to  dilate  the  cervix  until  the  fingers  can  be  passed  through. 


UTERINE  DILATORS. 


131 


Hegar's  dilators  consist  of  a  series  of  slightly  curved  stems  4|^  in.  to 
5i  in.  (12-14  cm.)  in  length,  with  a  short  flat  handle  2  in.  long,  numbered 
from  1  to  30  and  with  diameters  ranging  from  about  TV  in.  to  1TV  in.  (2-30 
mm.).  There  is  little  doubt  that,  to  prevent  sepsis,  vulcanite  dilators  are 
the  best.  For  dilating  the  cervical  canal  quickly  in  order  to  explore  the 


FIG.  97. 
HANKS'  DILATOR.  (}) 


uterine  cavity  with  the  finger,  for  the  removal  of  polypi,  or  for  curetting, 
they  are  specially  indicated  and  are  to  be  used  as  follows.  In  a  case,  for 
instance,  where  the  cervical  canal  is  to  be  dilated  in  order  to  gain  access 
for  the  removal  of  a  polypus,  the  patient  is  chloroformed,  placed  in  the 


30 


FIG.  97A. 

HEGAR'S  DILATOR.  The  lower  figure  represents  the  dilator  (No.  15)  complete,  reduced  to  one-third 
scale  ;  the  two  upper  figures  show  cross  sections  of  the  smallest  (No.  1)  and  the  largest  (No. 
30)  sizes. 

lithotomy  posture  and  the  vaginal  douche  employed.  Hegar's  dilators, 
which  are  lying  in  a  solution  of  corrosive  sublimate  1  in  2000,  are  then 
passed,  until  sufficient  dilatation  is  obtained.  The  polypus  is  then 
removed,  and  the  uterine  cavity  carefully  douched. 

We  recommend  therefore  the  use  of  the  tupelo  tents  in  cases  of 
threatened  abortion  where  the  practitioner  has  not  sufficient  assistance 
to  enable  him  to  use  the  vulcanite  dilators.  Where,  however,  this 
assistance  can  be  procured,  especially  for  exploration,  curetting,  and 
endometric  applications,  Hegar's  dilators  are  the  safest  and  best. 


CHAPTER  XIV. 

THE  CURETTE. 

LITERATURE. 

Mundi — The  Dull  Wire  Curette  in  Gynecological  Practice  :  Ed.  Med.  Jour.,  XXIII.,  p. 
819.  Recamier — Memoire  sur  les  Productions  Fibreuses  et  les  Fongosite's  Intra- 
ute'rines :  Univ.  Med.,  1850.  Simon — Die  Ausloffelung  breitbasiger  weicher  sar- 
komatoser  und  carcinomatoser  Geschwiilste  aus  Korperhohlen :  Beitrage  zur 
Geburtshulfe  von  der  Gesellschaft  in  Berlin,  1872.  Sims,  J.  Marion — Clinical 
Notes  on  Uterine  Surgery :  London.  Thomas — Diseases  of  Women :  London, 
1882. 

Curette.  THE  curette  is  an  instrument,  provided  with  a  cutting  or  a  dull  edge, 
which  can  be  introduced  into  the  uterine  cavity  (previously  dilated  by 
tents  if  necessary)  for  the  purpose  of  scraping  off  or  removing  abnormal 
endometric  granulations,  sarcoma  of  the  mucous  membrane,  carcinoma 
of  the  cervix,  or  the  remains  of  an  incomplete  abortion.  This  instrument 
has  had  a  somewhat  chequered  career.  Originally  introduced  by 
Recamier,  whose  instrument  was  stiff  and  sharp,  it  did  good  work  in 
some  cases ;  but  fell  into  disrepute,  undoubtedly  deserved,  after  the 
record  of  certain  instances  where  its  use  had  caused  perforation  of  the 
uterus.  Marion  Sims  and  Simon  recommend  a  modified  instrument 


FIG.  98. 

LOOP  OF  RECAMIER'S  CURETTE.  (}) 


which,  owing  to  its  stiff  unyielding  nature,  did  not  at  first  find  much 
favour  with  the  profession.  Thomas  then  introduced  his  flexible  dull 
wire  curette,  but  this  has  now  been  found  too  feeble  and  a  return  has 
been  made  to  stronger  instruments. 

There  are  four  varieties  of  curette — (1.)  Recamier's  (fig.  98);  (2.) 
Simon's  (fig.  99);  (3.)  Thomas'  (fig.  100);  (4.)  Martin's  (fig.  101).  Of 
these  we  recommend  Martin's. 

Ca8e*  in  which  the  Curette  is  «*5/W-— The  curette  may  be  used  to 
remove  a  piece  of  intrauterine  tissue  for  aid  in  diagnosis.  It  is  most 
frequently  employed  to  remove  abnormal  tissue,  in  abortion,  sarcoma 
tous  or  carcinomatous  diffuse  growth,  and  endometritic  conditions. 


THE  CURETTE.  133 

Method  of  Use. — We  take  curetting  for  incomplete  abortion  as  a  type 
of  procedure.  The  instruments  necessary  are  Sims'  speculum,  volsella, 
Hegar's  dilators,  sound  or  probes  armed  with  cotton  wool,  and  Fritsch's 
uterine  double  catheter  (fig.  110).  The  instruments  are  placed  in 
carbolic  lotion  (1-20)  or  in  biniodide  of  mercury  (1-2000).  The 


F™'  "•  Simon's 

SIMON'S  SPOON.  (§)  Spoon. 


patient  is   placed  semiprone  or,   if  chloroform  is  given,  in  the  litho- 
tomy posture:  the  speculum  is  passed  and  the  cervix  steadied  with 


FIG.  100. 
THOMAS'  DULL  WIRE  CURETTE,  with  knob  added  by  A.  R.  Simpson.  (J) 

a  volsella.  Hegar's  dilators  are  now  introduced  until  the  cervical 
canal  is  patulous  enough  to  admit  the  index  finger.  The  curette  is 
then  employed  by  being  passed  systematically  over  the  anterior  and 

_  __  M       ,,  ,  ,,,  ,tfij_  _  ___  ^-sssss^'3  Martin's 

^^^~^~==^"^smirF^..^_-;"    _~^Tr-"-     --=^~?f-—*^  Curette. 

FIG.  101. 
MARTIN'S  CURETTE. 

posterior  surfaces  from  above  downwards.  No-force  is  required,  and  the 
finger  can  make  out  by  the  feeling  of  the  curette  when  the  resistant 
muscle  is  reached. 

The  cavity  of  the  uterus  is  then  washed  out  with  a  mercurial  lotion, 
and  pure  carbolic  acid  applied. 

Cautions  and  dangers.  —  The  same  precautions  should  be  used  as  given  Cautions 
under  sponge  tents.  The  dangers  have  proved  in  the  authors'  hands  ??d  s 
slight,  a  minor  attack  of  pelvic  peritonitis  being  the  worst. 

RELATION  OF  POSTURE  TO  EXAMINATION  AND  TREATMENT. 

We  have  already  mentioned  several  postures  as  being  the  proper  ones 
for  certain  manipulations  ;  and  we  here  sum  up  briefly  what  it  is  of  use 
to  know  in  regard  to  these. 

The  lateral  posture,  where  the  patient  lies  on  her  side  in  the  ordinary 


134     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

way,  is  convenient  for  vaginal  examination;  for  the  use  of  Fergusson's, 
Nengebauer's,  or  disco's  speculum,  and  the  passage  of  the  sound  and 
catheter. 

The  dorsal  posture  is  imperative  for  abdominal  examination  and  the 
bimanual. 

The  semiprone  is  the  best  posture  for  passage  of  Sims'  speculum 
or  for  vesico-vaginal  fistula  operation. 

The  litJiotomy  posture  is  specially  valuable  for  operations  on  the 
perineum,  vaginal  walls,  cervix  and  uterus. 

The  genupectoral  posture  is  used  in  replacement  of  the  retroverted 
uterus. 


CHAPTER  XV. 

KNIVES ;  SCISSORS  ;  NEEDLES ;  SUTURES ;  DOUCHES  AND 
SYRINGES;  CAUTERY;  ANESTHETICS. 

KNIVES. 

FOR  perineal  operations,  the  surgeon's  ordinary  straight  bistoury  is  suffi-  Knives, 
cient.     For  vaginal  and  cervical  surgery,  long-handled  knives  with  the 
blade  straight  or  at  an  angle  to  the  shaft  are  required  (v.  under  operation 
for  vesico-vaginal  fistula). 

SCISSORS. 

These    are    of  the    greatest  use  to   the   gynecologist    and  in  many  Scissors, 
instances  supersede    the    knife.       Straight    sharp  -  pointed  scissors  are 
valuable  in  repair  of  the  perineum.     Curved  scissors  are  necessary  for 
fistula  cases  (fig.  102),  Bozeman's  being  specially  good.     They  are  right 


FIG.  102. 

SIMPLE  CURVED  SCISSORS. 

and  left,  but  no  woodcut  gives  a  proper  idea  of  their  curves.  For  cervical 
operations,  stout  and  sharp  scissors  are  necessary.  It  is  very  important 
to  remember  that  the  vaginal  portion  of  the  cervix  is  exceedingly  tough, 
and  that  the  ordinary  scissors  in.  dividing  it  slip  down  or  even  turn 
obliquely,  leaving  the  tissue  uncut.  Kuchenmeister's  scissors  have  this 
tendency  obviated  by  one  of  the  blades  being  hooked  (fig.  103).  Even 
these  scissors  sometimes  prove  unsatisfactory,  as  the  finger-and-thumb 
grip  they  give  is  not  powerful  enough.  Fig.  104  shows  a  pair  of  cervical 
scissors  devised  by  Hart,  where  the  handles  are  like  those  of  bone  forceps, 
and  are  provided  with  a  ratchet.  They  can,  therefore,  be  grasped  in  the 


136     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 


of  the  hand  while  being  used,  and  cut  even  the  densest  cervix  with 
great  precision.  Scissors  are  highly  useful  in  perineal,  vaginal,  and 
cervical  operations. 


FIG.  103. 

KUCHENMEISTER'S  SCISSORS. 


FIG.  104. 
HART'S  CERVICAL  SCISSORS. 


HMQw. 


NEEDLES. 

We  need  only  note  that  for  cervical  and  fistula  operations  strong 
short  needles  either  curved  or  perfectly  straight  are  needed.  The 
cervical  tissue  is  so  dense  that  markedly  curved  needles  snap  when  slight. 


SYRINGES  AND   DOUCHES. 


137 


They  are  passed  with  a  needle-holder,  of  which  fig.  106  shows  a  simple  ^eedle 
form.       Curved    or  tubular  needles   set    on    handles    are    also   useful. 


Holders. 


FIG.  105. 

FOKMS  OF  NEEDLE  (Emmet). 


Hagedorn's  needles  are  flattened  laterally  and  full-curved.     A  special 
needle-holder  is  necessary  for  them. 


FIG.  106. 

NEEDLE-HOLDER. 

SUTURES. 

These  may  be  silver  wire,  carbolized  silk,  catgut,  silk-worm  gut,  or 
horse-hair.  For  fistuke,  deep  stitches,  and  cervical  lacerations,  silver  wire 
or  silk  is  used.  For  perineal  operations,  for  superficial  stitching,  as  also 
for  stitching  the  ovariotomy  incision,  silk-worm  gut  is  good.  Catgut  is 
valuable  in  the  rectal  stitches  of  complete  rupture  of  the  sphincter  ani ; 
and  is  now  largely  used  instead  of  silk  for  operations  on  the  cervix, 
vagina,  and  perineum,  as  it  obviates  the  necessity  of  removing  the 
stitches  afterwards.  Carbolized  silk  (thin  and  fine)  is  best  for  the 
ovariotomy  pedicle.  Horse  hair  is  useful  for  superficial  skin  stitches. 

VAGINAL  SYRINGES  AND  DOUCHES :  UTERINE  DOUCHE. 
For  the  purpose  of  applying  antiseptic  and  astringent  lotions  to  the 
vagina  and  split  cervix,  for  hot-water  injections,  and  for  merely  cleansing 


FIG.  107. 

HICGINSON'S  SYRINGE. 


purposes,  the  vaginal  syringe  and  douche  are  employed.  . 

Vaginal  Syringes. — Fig.  107  shows  the  well-known  Higginson  syringe.  Syringe. 


Vaginal 
Douche. 


138     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

Valuable  as  this  is,  it  is  difficult  for  ordinary  patients  to  manage  single- 
handed.  For  them  we  should  therefore  recommend  the 

Vaginal  Doudie. — A  convenient  form  of  this  is  shown  at  fig.  108.  It 
can  be  hung  up  after  being  filled,  and  a  gentle  flow  is  thus  obtained 
by  gravitation.  The  overflow  from  the  vagina  is  received  into  any  suit- 
able receptacle  on  which  the  patient  sits. 

For  patients  in  bed  its  use  is  equally  easy.  The  nurse  or  attendant 
should  be  instructed  to  make  the  patient  lie  on  her  back,  her  hips  being 
well  raised  with  a  pillow.  The  pillow  itself  should  be  covered  with  a 
waterproof  or  folded  blanket.  An  ordinary  basin  is  then  slipped  below 
the  hips  to  receive  the  overflow. 

Instead  of  the  douche,  a  simple  tube  working  by  syphon  action  may  be 


FIG.  108. 

VAGINAL  DOUCHE. 


FIG.  109. 
SYPHON  DOUCHE. 


employed.  This  consists  of  a  "sinker,"  a  long  piece  of  gutta  percha  tubing 
with  a  bent  piece  of  glass  tubing  inserted  so  as  to  render  it  rigid  where 
it  passes  over  the  edge  of  the  vessel  containing  the  fluid,  and  a  terminal 
vaginal  tube.  The  "  sinker  "  should  be  large  and  hollow,  so  that  when 
inverted  it  may  serve  as  a  cup  by  which  the  tube  may  be  filled  with 
water ;  once  filled,  the  tube  is  temporarily  compressed  while  the  sinker 
is  being  dropped  into  the  jug  or  pail  full  of  water  ready  for  use. 

The  great  advantage  of  the  douche  is  its  simplicity.  Half  of  the 
women  who  buy  a  Higginson  do.  not  know  how  to  use  it,  and  find  it 
troublesome  even  when  they  do  know. 

Medicated       The  material  for  injection  is  various.     Hot  water,  as  hot  as  the  patient 
'  can  bear  it,  is  invaluable  in  inflammatory  conditions. 

Hot  carbolic  lotion  (equal  parts  of  boiling  water  and  1—20  lotion)  is 
admirable  for  cleansing  purposes  in  abortion  cases. 


SYRINGES  AND  DOUCHES.  139 

In  leucorrhoeal  conditions,  injections  of  alum  (5j  to  oj),  sulphate  of 
copper  (3ss  to  oj),  sulphate  of  zinc  (3ss  to  oj)  are  good.  The 
general  formula  for  these  is — • 

R  Aluminis 

vel 
Cupri  Sulphatis, 

vel 

Zinci  Sulphatis  5j- 
Fiat  pulv ;  mitte  tales  xij. 
Sig.   To  be  used  as  directed. 

The  patient  is  told  to  dissolve  one  powder,  or  half  of  one,  in  a  pint  of 
water,  to  place  this  in  a  douche  and  use  as  already  explained. 

It  is  a  good  plan  to  make  the  patient  first  douche  with  hot  water 
and  then  finally,  in  the  dorsal  posture,  to  end  with  the  special  lotion. 
After  it  is  finished  the  dorsal  posture  should  be  maintained  for  ten 
minutes,  and  the  last  of  the  injection  expelled  by  sitting  up. 

The  Uterine  Douche  is  to  be  employed  only  after  the  cervical  canal  uterine 
and  uterine  cavity  have  been  so  far  dilated  as  to  admit  the  index  finger.  Douche- 


FIG.  110. 

FRITSCH'S  CATHETER  FOB  WASHING  OUT  THE  INTERIOR  OF  THE  UTERUS. 

Aii  ordinary  vaginal  douche  or  Higginson  syringe  may  be  employed ; 
if  the  former,  a  clean  catheter  is  substituted  for  the  vaginal  tube  ;  with 
the  latter,  it  is  best  to  place  the  catheter  at  the  one  end  of  a  long  piece 
of  indiarubber  tubing,  the  other  end  of  the  tubing  being  attached  to  the 
syringe.  In  giving  a  uterine  douche  after  the  removal  of  abortion  or 
fibroid  polypus,  the  vulva  and  vagina  should  first  be  thoroughly  douched. 
Care  must  be  taken  to  give  the  uterine  douche  gently  and  slowly, 
allowing  free  exit  of  the  fluid,  and  carefully  excluding  air  from  the 
apparatus.  The  size  of  the  uterine  tube  should  never  be  such  as  to  fill  the 
cervical  canal.  The  best  uterine  tube  is  Fritsch's  (fig.  110),  or  some  of 
its  modifications,  as  the  double  canula  entirely  obviates  any  retention 
of  fluid.  Passage  of  the  fluid  through  a  patent  Fallopian  tube  into  the 
peritoneal  cavity  is  one  of  the  risks  but  can  usually  be  avoided  by  giving 
the  injection  gently. 

The  uterine  douche  is  used  once  only,  immediately  after  the  operation, 
unless  septic  symptoms  arise.  In  the  after  treatment,  the  vaginal  douche 
is  sufficient. 


140    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

CAUTERY. 

Cautery-      The  ordinary  cautery  may  be  employed  in  the  treatment  of  the  pedicle 
Paquehn's.  -n  ovariotonly.     Details  are  postponed  till  that  subject  is  considered. 

In  the  well-known  Paq'uelin's  cautery,  the  vapour  of  benzoline  is 
pumped  through  a  slender,  hollow  cone  of  platinum,  which  has  been 
previously  heated  in  a  gas  flame  or  spirit  lamp.  It  speedily  becomes  red 
or  white  hot  by  the  combustion  of  the  vapour,  and  can  then  be  used. 

Note  as  to  its  use  :  (1)  To  be  careful  with  the  benzoline  as  it  is 
exceedingly  inflammable  ;  (2)  To  heat  the  platinum  cone  first  (in  outer- 
most zone  of  the  flame)  before  pumping  in  the  benzoline.  If  the  vapour 
is  pumped  in  before  the  platinum  is  hot  enough  to  ignite  it,  the  cone  is 
cooled  by  its  cold  stream. 

The  cautery  should  be  used  at  a  dull  heat.  When  white  hot  it  causes 
bleeding,  because  it  thoroughly  burns  the  tissues  and  thus  leaves  no  char 
to  act  as  a  haemostatic. 

When  used  to  cauterize  the  cervix,  care  is  necessary  that  the  hot 
metal  rod  does  not  touch  the  vaginal  walls.  Various  plans  have  been 
tried  to  prevent  this  accident.  Thus  the  rod  may  be  covered  except  at 
its  terminal  two  inches  with  a  wooden  case  which  must  not  touch  the 
metal.  Fig.  Ill  shows  some  of  the  various  rods  of  Paquelin's  cautery. 

ANESTHETICS. 

LITERATURE.  Brunton,  T.  L.—  Remarks  on  One  of  the  Causes  of  Death  during  the 
Extraction  of  Teeth  under  Chloroform :  Br.  Med.  J.,  II.,  1875,  p.  395.  Chiene— 
Chloroform :  London  Practitioner,  January  1877.  Hart,  D.  B.  —  On  Death 
from  Insufficient  Administration  of  Chloroform:  Ed.  Med.  J.,  1879.  Lister— 
Chloroform  :  Holmes'  System  of  Surgery,  Vol.  V.  Report  of  Br.  Med.  Ass.  Com- 
mittee :  Br.  Med.  J.,  Vol.  I.,  1879.  Murray,  B.  Milne— The  Cessation  of 
Respiration  under  Chloroform  and  its  Restoration  by  a  new  method  :  Edin.  Med. 
J.,  1885.  See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

Ansesthe-  THE  chief  anesthetics  are  chloroform  and  ether.  Other  agents  or  mix- 
tures have  been  tried — viz.  ethidene ;  mixtures  of  alcohol,  ether,  and 
chloroform ;  nitrous  oxide ;  bichloride  of  methylene  :  the  results  have 
not  been  satisfactory  with  these.  In  the  British  Medical  Report  on  the 
action  of  anesthetics,  ethidene  is  strongly  recommended.  Chloroform 
and  ether,  however,  still  remain  our  most  trustworthy  agents. 
Action  of  Action  of  Chloroform. —  Chloroform  when  administered  to  a  patient  has 
form™  a  perfectly  definite  effect  on  the  nervous  system.  Sensation  is  first 
abolished,  and  then  reflex  action.  This  is  all  the  effect  wished  for  in 
any  case.  If,  however,  the  chloroform  be  pushed  further,  the  respiratory 
centre  becomes  paralysed  so  that  breathing  ceases ;  and  finally  the  heart 
stops  from  paralysis  of  its  ganglia.  In  almost  all  cases  this  is  the  sequence 
in  the  susceptibility  to  chloroform  of  the  parts  of  the  nervous  system 
regulating  'sensation,  reflex  action,  respiration,  and  the  circulation. 
Rarely  have  we  the  heart  affected  before  the  respiratory  centre.  When 


ANAESTHETICS. 


141 


first  administered,  it  causes  a  transient  rise  in  the  blood  pressure ;  and 
then  a  gradual  irregular  fall.  The  more  recent  investigators  on  this 
point  (see  the  British  Medical  Report)  found  that  in  dogs  chloroform 
reduced  the  blood  pressure  more  rapidly  and  to  a  greater  extent  than 


FIG.  111. 
VARIOUS  FORMS  OF  PAQUELIN'S  CONES.    A  rectangular ;  B  curved  ;  C  straight. 

ethidene,  and  that  ether  did  not  cause  any  appreciable  depression.  As 
the  blood  pressure  is  the  resultant  of  the  force  and  frequency  of  the 
heart's  action  and  the  state  of  dilatation  of  the  small  blood-vessels,  it  is 
evident  that  chloroform  when  administered  to  dogs  slowed  the  heart  and 
weakened  the  vasomotor  centre  more  than  ethidene  or  ether.  It  should 


142     PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

be  kept  in  mind,  however,  that  dogs  are  very  susceptible  to  the  action  of 
chloroform  and  easily  killed  by  it. 

Death  not       It  is  wrong  to  suppose  that  in  every  death  under  chloroform  the  fatal 
to^er-'  U°  result  is   caused  by  -an  over-dose,   or  by  the  action  of  the   drug  on 
dose.          a  fatty   heart.      This   is   a  very  common   view,  but   an   exceeding^ 
erroneous  one. 

To  prevent  the  patient's  feeling,  though  one  of  the  most  gratifying 
results  of  anaesthesia,  is  not  by  any  means  the  great  object  in  operative 
cases.  One  of  the  most  essential  aims  of  its  administration  is  to  prevent 
the  reflex  transmission  of  powerful  nervous  impulses  from  the  part  oper- 
ated on  to  the  heart,  or  their  direct  transmission  to  the  respiratory  or  vaso- 
motor  centres.  If  chloroform  be  administered  to  a  limited  extent  so 
that  sensation  alone  is  abolished,  and  any  large  nervous  trunk  like  the 
Fifth,  or  large  nervous  area  like  the  splanchnic,  be  irritated,  then  we 
may  have  reflex  inhibition  of  the  heart  or  paralysis  of  the  vasornotor  and 
respiratory  centres ;  in  man,  death  may  result.  There  are  reliable  clin- 
ical reports  that  this  reflex  inhibition  of  the  heart  has  caused  its  stoppage 
in  man.  It  is  sometimes  urged  against  this  that  no  amount  of  stimu- 
lation of  the  lower  end  of  the  cut  vagus  in  a  rabbit  can  permanently 
stop  its  heart ;  in  man,  however,  the  conditions  are  not  the  same  as  in 
the  rabbit.  Goltz,  quoted  by  Lauder  Brunton,  gives  some  most  inter- 
esting facts  in  this  connection.  A  frog  was  decapitated,  its  heart  exposed, 
and  the  animal  hung  with  its  legs  downwards.  On  tapping  the  intes- 
tines pretty  hard,  the  heart  stopped  through  reflex  inhibition  of  the  vagus 
but  soon  resumed  again.  It  contracted  vigorously  but  had  no  blood  in 
it  to  propel.  The  irritation  of  the  splanchnics  had  not  only  inhibited 
the  heart  but  so  lowered  the  tone  of  the  vasomotor  centre  that  the  veins 
of  the  abdominal  cavity  were  widely  dilated  ;  and  thus  the  blood,  when 
the  animal  was  vertical,  did  not  reach  the  opening  of  the  inferior  vena 
cava  into  the  right  auricle.  When  the  frog  was  laid  on  its  back,  how- 
ever, the  blood  flowed  at  once  to  the  heart. 

This  then  gives  us  the  proper  view  of  the  administration  of  chloroform 
in  all  cases  where  cutting  operations  or  operations  involving  large  nervous 
trunks  are  being  performed  :  the  chloroform  must  be  pushed  until  sensation 
and  reflex  action  are  abolished,  and  this  state  is  to  be  kept  up  during  the 
operation. 

Uses.  Uses. — Chloroform  is  used  in  all  cutting  operations  except  very  slight 

ones ;  where  the  straining  of  the  patient  prevents  the  manipulation 
necessary  for  accurate  diagnosis  and  treatment ;  in  phantom  tumours ; 
and  also,  when  necessary,  in  cases  where  vaginal  examination  of  virgins 
is  indicated. 

In  division  of  the  cervix,  curetting  of  the  eudometrium,  and  applica- 
tion of  caustics  to  the  endometrium,  it  is  unnecessary  unless  the  patient 
is  unusually  sensitive. 


ANAESTHETICS. 


143 


Method  of  administration. — The  patient  should  have  no  food  for  three  Method  of 
or  four  hours  prior  to  the  operation.     Just  before  the  administration 
chloroform  is  begun,  half  a  glass  of  wine  or  brandy  may  be  given. 

The  patient  lies  on  the  back  with  all  fastenings  unloosed,  and 
should  not  sit  up.  A  towel  or  napkin  folded  square  is  taken  and  chloro- 
fjorm  poured  on  it.  Fig.  112  shows  a  convenient  and  economical  drop- 
cork  which  can  be  fitted  into  any  bottle.  The  amount  does  not  matter. 
We  judge  of  the  amount  of  chloroform  required  not  by  the  quantity 
poured  on  the  cloth  but  by  the  effect  on  the  patient.  If  reflex  action 
be  not  abolished,  even  though  a  quart  has  been  used,  the  patient  has 


FIG.  112. 

CHLOROFORM  DBOP  CORK. 

not  had  enough  ;  while  if  respiration  be  affected  after  a  few  whiffs, 
she  has  had  too  much. 

The  face  of  the  patient  should  look  to  the  side,  and  the  chin  should  be 
kept  well  away  from  the  sternum.  The  administrator  keeps  the  chin 
forward  with  his  right  hand.  This  has  the  additional  advantage  of 
allowing  him  to  feel  the  piiff  of  the  breath  on  the  palm. 

The  cloth  is  to  be  held  not  too  closely  over  the  face  and  the  patient 
directed  to  take  long  breaths. 


144    PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

The  administrator  has  to  keep  two  points  before  him.  He  is  to  watch- 
the  breathing  most  narrowly,  and  to  ascertain  when  reflex  action  is 
abolished. 

He  can  watch  the  breathing  well  by  feeling  the  puff  of  the  breath  con- 
stantly  on  his  hand.  The  abolition  of  reflex  action  is  generally  tested 
by  touching  the  conjunctiva;  when  the  patient  is  not  fully  under,  the 
orbicularis  contracts.  This  is  not  a  perfect  test,  but  the  best  we  have. 

When  reflex  action  is  abolished,  no  more  chloroform  is  to  be  given  ; 
should  it  show  signs  of  returning,  fresh  chloroform  is  put  on  the  cloth. 

DANGERS. 

These  are  the  following  : — 

Dangers.  (!•)  Asphyxia; 

(2.)  Reflex  inhibition  of  heart  or  respiratory  or  vasomotor  centres. 

(1.)  Asphyxia. — This  may  arise  early  from  fainting,  muscular  relaxa- 
tion allowing  the  tongue  to  fall  back  on  the  pharynx ;  or  from  closure 
of  the  glottis,  owing  to  paralysis  of  its  intrinsic  muscles.  The  marked 
extension  of  the  head  already  insisted  on  prevents  the  former  from  hap- 
pening. If  it  arise,  the  tongue  is  to  be  pulled  well  forward  with  a  pair 
of  forceps.  Foulis  recommends  that  the  tongue  be  pressed  forward  by  a 
spatula  or  spoon  applied  at  its  root. 

When  asphyxia  arises  from  paralysis  of  the  respiratory  centre  owing 
to  an  overdose  of  chloroform,  the  treatment  is  immediate  stoppage  of  the 
administration  of  the  chloroform  and  artificial  respiration  by  Sylvester's 
or  Howard's  method  for  hours  if  necessary.  The  head  should  be  kept 
hanging  over  the  edge  of  the  table,  so  as  to  send  blood  to  the  respira- 
tory centre ;  or  the  patient  may  be  inverted  (Nelatonized).  Recently, 
Milne  Murray  in  an  elaborate  research  has  pointed  out  the  interesting 
practical  fact  that  artificial  respiration  must  in  the  first  place  send 
more  chloroform  through  the  system,  inasmuch  as  the  lung  is  charged 
with  chloroform  vapour.  He  therefore  advocates  aspiration  of  the 
chloroform  vapour  from  the  lungs  prior  to  beginning  artificial  respir- 
ation. For  this  purpose  he  recommends  that  a  gum  elastic  catheter, 
provided  with  a  conical  collar  to  fit  the  glottis,  be  passed  into  the 
trachea  and  the  air  be  sucked  by  the  administrator  from  the  lungs. 
When  this  has  been  done  several  times  the  tube  should  be  partially 
withdrawn  so  as  to  remove  the  conical  collar  from  the  glottis,  and 
pernation  employed :  i.e.,  the  chloroform  vapour  is  still  sucked  from  the 
lung,  but  air  now  passes  in  between  the  tube  and  trachea,  and  thus  a 
current  is  established.  When  all  traces  of  chloroform  vapour  have 
disappeared,  ordinary  artificial  respiration  should  be  practised. 
Reflex  In-  (2.)  Reflex  inhibition  of  the  heart  or  respiratory  or  vasomotor  centres. — 
This  can  only  happen  when  there  has  not  been  given  sufficient  chloroform 
to  abolish  reflex  action.  It  is  by  no  means  an  uncommon  thing,  there- 


ANAESTHETICS.  145 

fore,  for  the  patient  to  die  because  sufficient  chloroform  has  not  been 
administered ;  sensation  alone  had  been  abolished  when  the  operation 
began.  The  usual  account  is  that  "  the  patient  gave  a  start  when  the 
first  incision  was  made,  and  died."  In  some  cases  this  has  happened 
after  only  a  teaspoonful  had  been  poured  on  the  cloth.  Yet  this  is  often 
called  "a  death  from  chloroform." 

Contra-indications. — Every  patient   on  whom  an  operation    is  to  be  Contra- 
performed   may  have  chloroform  ;  if  the   operation   is  indicated,  so  is  tions. 
chloroform.     If  the  patient  has  a  weak  heart,  then  chloroform  is  impera- 
tive for  any  major  operation  ;  it  must  be  given  till  reflex  action  is  abol- 
ished, as  reflex  inhibition  of  the  heart  is  specially  dangerous  here. 

Occasionally,  chloroform  causes  severe  vomiting  after  the  operation.  Vomiting. 
For   this   reason    Keith    always    uses    ether.       Vomiting   during   the 
operation  is  dangerous  only  when   any  solid  matter  regurgitates   back 
into  the  trachea  ;  tracheotomy  may  then  be  necessary. 

Sickness  after  the  operation  is  treated  by  the  sucking  of  ice  and  the 
application  of  a  mustard  leaf  to  the  pit  of  the  stomach. 

COCAINE,*  introduced  by  Roller  as  a  local  anaesthetic,  is  coming  to 
be  much  used  in  Gynecology,  especially  in  the  removal  of  urethral 
caruncles,  Emmet's  operation,  ligature  of  piles,  and  plastic  operations 
on  the  perineum.  A  solution  of  the  hydrochlorate  (4 — 20  p.  c.)  is  the 
one  usually  employed. 

*  See  T.  L.  Brunton— Pharmacology,  Therapeutics  and  Materia  Medica :  London,  1885.  Many 
papers  on  the  use  of  Cocaine  in  Gynecology  will  be  found  under  "Anaesthesia"  in  the  Index  of 
Recent  Literature  in  the  Appendix. 


CHAPTER    XVI. 

RELATION  OF  MICRO-ORGANISMS  TO   GYNECOLOGY: 
ANTISEPTICS. 

LITERATURE. 

Barbour— Puerperal  Septicaemia  :  Edin.  Med.  Journ.,  Nov.  1885  ;  Discussion,  Feb.  188G. 
Bockhart — Beitrag  zur  jEtiologie  und  Pathologic  des  Harnriihrentrippers  :  Viertel- 
jahrschrift  f.  Derm.  1883,  Heft  1.  Brunton,  T.  L.—  Pharmacology,  Thera- 
peutics, etc. :  London,  1885.  Bumm — Beitrag  zur  Kenntniss  der  Gonorrhoe  der 
weiblichen  Genitalien :  Arch.  f.  Gynak.,  Bd.  XXIII.  S.  327.  Cheyne,  W.  W.— 
Antiseptic  Surgery :  London,  1882.  Manual  of  the  Antiseptic  Treatment  of 
Wounds  :  London,  1885.  Davaine — Rechercb.es  relatives  k  1 'action  des  substances 
antiseptiques  sur  le  virus  de  la  septice'mie  :  Com.  Rend.  Soc.  de  Biolog.,  Tom.  I., 
6th  Series,  p.  25.  Dougall — On  the  Prevention  of  Putrefaction  and  the  Destruc- 
tion of  Contagia :  Glasgow  Med.  Journal,  Vol.  VII.  Klein — Micro-organisms 
and  Diseases  :  Lond.  1884.  Koch — Article  "  Ueber  Desinfection  "  in  Mittheilungen 
aus  dem  kaiserlichen  Gesundheitsamte :  Berlin,  1881.  La  Place — Saure  Sublimat- 
losung  als  desinficirendes  Mittel  und  ihre  Verwendung  in  Verbandstoff  en  :  Deutsch. 
Med.  Woch.,  Leipz.,  1887,  XIII.,  866.  Lister,  Sir  J.—On  Corrosive  Sublimate  as  a 
Surgical  Dressing  :  Lancet,  1884,  p.  223.  Lomer — Our  present  Knowledge  of  the 
Relations  between  Micro-organisms  and  Puerperal  Fever  :  Am.  Journ.  of  Obstet., 
Vol.  XVII.,  p.  673.  Lusk — Nature,  Origin,  and  Prevention  of  Puerperal  Fever  : 
Intern.  Congr.  Tr.,  1876.  Also  article  "Puerperal  Fever  "  in  Pepper's  Practical 
Medicine,  1885.  Neisser — Die  Mikrokokken  der  Gonorrhoe  :  Deutsch  Med.  "Woch. 
1882,  No.  20,  S.  279.  Petit — Sur  les  substances  antifermentescilles :  Comptes 
Rendus de  1'Academie des  Sciences,  1872.  Russell,  J.  A. — Article  "Disinfection  : " 
Quain's  Diet,  of  Medicine,  1883.  Stadfeldt— Sind  als  Desinficiens  in  der  Geburt- 
shiilfe  Sublimatlosungen  der  Karbolsaure  vorzuziehen:  Centralbl.  f.  Gyn.  1884, 
No.  7.  Tarnier — Contribution  to  Discussion  on  Spiegelberg's  paper  on  "  Antisepsis 
in  Geburtshiilfe  : "  Transactions  of  London  Intern.  Congress,  Vol.  IV.,  1881,  p.  390. 
Woodhead,  O.  S. — Notes  on  the  use  of  Mercuric  Salts  in  Solution  as  Antiseptic 
Surgical  Lotions :  Proc.  of  Roy.  Soc.  Edinr,  1888.  v.  also  Reports  of  Laboratory, 
R.C.P.E.,  1888.  Woodhead  and  flare— Pathological  Mycology:  Edinr.  1885. 
Ziegler— Pathologische  Anatomic,  Bd.  II.  S.  805.  The  U.S.A.  Catalogue  gives  full 
references  under  Antiseptics  and  Disinfection.  See  also  Index  of  Recent  Gyneco- 
logical Literature  in  the  Appendix. 

RELATION    OP   MICRO-ORGANISMS    TO    GYNECOLOQY. 

ofemicro-8  THE  recent  advances  in  regard  to  the  part  played  by  micro-organisms  in 
organisms  the  etiology  of  disease  have  not  been  shared,  to  any  great  extent,  by 
oology"!6  Gynecology.  Steurer,  who  investigated  an  epidemic  of  puerperal  fever  at 


ANTISEPTICS.  147 

Strassburg,  found  cases  with  diphtheritic  patches  about  the  vulva ;  and 
from  these  traced  bacteria  into  the  connective-tissue  spaces  where  their 
presence  gave  rise  to  cellulitis ;  from  the  spaces,  they  entered  the  lym- 
phatics causing  lymphangitis.  Klebs,  who  terms  the  bacteria  found 
in  a  wound  "microsporon  septicum,"  traced  their  extension  (with  or 
without  the  aid  of  wandering  white  blood-corpuscles)  from  serous 
membranes  into  the  connective  tissue  and  noted  their  penetration 
through  the  eroded  wall  of  a  vein.  Recklinghausen  found  the 
lymphatics  of  the  skin,  at  the  edge  of  an  erysipelatous  patch,  filled  with 
bacteria. 

Gynecologists  have  thus  been  led  to  suspect  that  pelvic  peritonitis 
and  cellulitis,  as  well  as  septiccemia  following  operations,  are  all 
caused  by  micro-organisms  or  their  products ;  but  as  yet  the  definite 
proof  of  this,  as  formulated  by  Koch,  has  not  been  forthcoming.  Although 
many  authors  have  pointed  out  that  various  micro-organisms  have  been 
found  in  the  tissues  after  death  from  such  diseases,  yet  the  four  criteria 
demanded  by  Koch  have  not  been  satisfied.  These  are  the  following  :  (1) 
The  micro-organisms  must  be  present  in  the  tissues  or  blood-vessels  of 
the  diseased  animal  or  man,  and  in  that  disease  only ;  (2)  a  pure  culti- 
vation of  these  must  be  obtained  ;  (3)  inoculation  with  this  must  give 
the  same  disease  to  an  animal  capable  of  receiving  it ;  (4)  in  the  tissues 
or  blood  of  this  newly  affected  animal  the  micro-organisms  must  be 
found,  and  in  the  same  relation  to  them  as  in  the  original  disease. 
Until  these  are  satisfied  we  shall  not  reach  such  demonstration  of  the 
relation  of  micro-organisms  to  these  diseases  as  we  have  in  the  case 
of  splenic  fever. 

It  is  to  be  hoped  that  the  application  of  the  processes  now  known  to 
pathologists  will  solve  this  problem. 

In  GonorrJuea,  however,  by  the  researches  of  Neisser,  Bockhart, 
Bumm,  and  others,  special  micrococci  have  been  found.  Bumm 
describes  these  as  diplococci  (i.e.  the  micrococci  are  dual),  half 
cylindrical,  and  measuring  in  length  2 '2-2 '5  //,.  Not  only  have  the 
micrococci  described  by  Neisser  been  isolated  so  as  to  give  a  pure 
cultivation,  but  gonorrhoea  has  been  caused  by  an  inoculation  with 
this  (Bockhart). 

Advances  have  also  been  made  in  our  knowledge  of  tubercular  diseases, 
as  the  bacillus  tuberculosis  has  been  found  in  peritonitis  and  Fallopian- 
tube  disease. 

ANTISEPTICS. 

By  an   Antiseptic  we    understand  an    agent  capable   of  destroying  Antiseptics, 
or    inhibiting    the     growth     of     the    septic     or     pathogenic     micro- 
organisms. 

Formerly,  the  evidence  of  the  antiseptic  properties  of  any  substance 


148      PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

was  considered  sufficient  if  it  kept  a  wound  free  from  foetor  and  caused 
no  blackening  of  the  protective  at  the  wound.  Owing  however  to 
increased  knowledge  as  to  the  nature  of  micro-organisms  arrived  at  by 
improved  methods  of  isolation  and  cultivation  on  gelatine  or  peptonised 
jellies,  more  exact  information  has  been  gained  as  to  the  trustworthiness 
of  our  many  antiseptic  agents. 

Thus  Dougall  of  Glasgow  mixed  vaccine  matter  with  carbolic  lotion 
(1-20)  and  left  it  exposed  for  twelve  days  ;  he  found  that  it  was  still  cap- 
able of  producing  the  usual  vaccine  pustule.  The  most  elaborate  and 
exact  researches  have,  however,  been  made  by  Koch,  and  his  results 
have  been  found  to  tally  with  subsequent  clinical  trial. 

Koch's  method  was  as  follows  :  he  dipped  sterilised  threads  in  culti- 
vations of  bacilli  not  containing  spores,  and  others  in  those  containing 
spores ;  the  former  were  then  immersed  in  a  solution  of  carbolic  acid 
(1  p.  c.)  for  two  minutes,  and  thereafter  placed  on  some  of  the  materials 
used  for  cultivation,  and  he  found  they  did  not  grow ;  the  latter  (i.e. 
those  with  spore-bearing  bacilli)  were  however  unaffected  after  being 
steeped  even  for  two  days  in  a  2  p.  c.  solution  of  carbolic  acid. 
Immersion  in  even  a  5  p.  c.  aqueous  solution  of  carbolic  acid  did 
not  render  the  spores  incapable  of  development.  5  p.  c.  solutions  in 
alcohol  and  in  oil  were  ineffective  on  the  spares  even  after  70  to  110 
days'  immersion ;  similar  solutions  destroyed  the  bacilli  after  six  days' 
immersion. 

The  most  powerful  germicide  was  found  to  be  corrosive  sublimate, 
which  in  weak  solutions  (1  in  20,000)  killed  spore-bearing  bacilli  almost 
immediately  and  inhibited  their  growth  when  of  a  strength  of  only  1  in 
30,000.  An  evident  difference  exists  between  micro-organisms  in 
relation  to  their  resistance  to  antiseptics :  bacilli  without  spores, 
and  micrococci,  are  readily  killed  by  a  1-20  aqueous  solution  of 
carbolic  acid,  while  spores  resist  immersion  in  1-20  carbolic  lotion  even 
for  days. 

Carbolic  oil  and  alcoholic  solutions  of  carbolic  acid  have  proved 
inefficient  as  antiseptics  and  should  therefore  be  discarded  in  prac- 
tice. 

These  researches  give  a  guide  in  determining  what  antiseptics  we 
should  use  but  require,  as  we  shall  see,  to  be  accepted  with  some 
modification. 

Activity  The  following  is  taken  from  a  table  given  by  Koch  of  the  activity  of 
. various  antiseptics.  The  double  underlining  means  that  after  that 
number  of  days  the  spores  of  the  bacillus  anthracis  were  taken 
out  of  the  fluid  and  found  to  be  no  longer  capable  of  development. 
When  the  numeral  is  not  so  underlined  it  means  that  after  immer- 
sion for  the  special  number  of  days  the  spores  were  still  capable  of 
growth. 


ANTISEPTICS. 


149 


FLUID. 

PERIOD  (in  days)  OF  THE 
IMMERSION  OF  THE 
SPORES  IN  THE  FLUID. 

REMARKS. 

Absolute  alcohol 

1      3      5    ...    110 

JEther 

158*                  30 

incomplete  growth. 

Oil  of  Turpentine 
Chlorine  water 

1*    5_10 
1      5 

*Isolated  but  well-mark- 
ed development. 

Bromine  (2  %  in  water) 

1_  _5_ 

Iodine  water 

1 

Iron  chloride 
Sublimate  (1  %  in  water) 

2*    6 
1_    2 

'Delayed   but  well    de- 
veloped. 

Thymol  (5  %  in  alcohol) 

1      6    10    15 

Salicylic  acid  (5  %  in  alcohol) 

1      6    10    15 

In  regard  to  thymol  and  salicylic  acid  it  should  be  noted  that  alco- 
holic solutions  were  used,  which,  like  oily  solutions  of  antiseptics,  are 
less  effective  than  aqueous  ones  :  e.g.  an  alcoholic  is  less  active  than  an 
aqueous  solution  of  iodine. 

We  must  now  consider  our  chief  antiseptics  from  the  clinical  stand- 
point. 

Carbolic  acid  is  in  many  respects  one  of  our  most  trustworthy  anti-  Carbolic 
septics.  A  watery  solution  of  1  in  20  is  thoroughly  effective  except  in 
the  case  of  spore-bearing  bacilli,  and  can  be  relied  on  in  operative  work. 
Frorn  its  not  acting  on  metals  and  having  no  injurious  action  on  sponges, 
it  is  useful  for  cleaning  these  as  well  as  for  skin  cleansing.  A  solution 
of  1  in  20  if  prolonged  in  its  use  has,  however,  a  disagreeable  action  on 
the  skin  and  the  odour  is  pronounced. 

Corrosive  sublimate  was  recommended  in  1874  by  Davaine,  vised  by  Tar- Corrosive 

J  J  pi__i_i; i_ 

nier  in  obstetrics  prior  to  1880,  and  was  very  many  years  ago  the  favourite ' 
antiseptic  of  the  late  A.  B.  Stirling,  assistant-curator  in  the  Edinburgh 
Anatomical  Museum,  so  well  known  for  his  freezing-microtome  and 
microscopic  work.  Since  Koch  found  it  the  only  germicide  for  the 
spores  of  bacillus  anthracis,  it  has  come  into  great  prominence. 

Solutions  of  1  in  2000,  1  in  4000,  1  in  8000  are  very  effective  ;  it  is 
undoubtedly  a  valuable  addition  to  antiseptics,  as  it  is  rapid  in  action, 
very  soluble,  odourless,  and  non-irritating  to  the  hands.  Its  corrosive 
action  on  instruments  and  injury  to  sponges  are  the  drawbacks  to 
its  use. 

Some  important  facts  as  to  the  action  of  corrosive  sublimate  on  soaps 


Sublimate. 


150      PHYSICAL  EXAMINATION  OF  PELVIC  ORGANS. 

and  blood  albumin  must  be  kept  in  mind.  With  ordinary  soaps, 
albumin,  or  blood,  we  get  insoluble  and  inert  compounds  formed. 
Thus  if  5  c.c.  blood  be  added  to  50  c.c.  corrosive  sublimate  (1-1000), 
nearly  all  the  mercury  is  thrown  down  as  albuminate  of  mercury. 
This  precipitation  of  the  mercury  is  prevented  however  by  the  addition 
of  tartaric  acid  or  common  salt,  so  that  £  p.c.  to  1  p.c.  salt  solution 
should  be  used  in  making  1  to  1000  corrosive  sublimate  (Woodhead). 

Messrs  Duncan,  Flockhart  <fe  Co.  have  made  a  special  bottle  (containing 
five  ounces)  with  a  cupped  glass  stopper  of  one  drachm  capacity.  The 
solution  of  corrosive  sublimate  is  of  such  a  strength  that  one  cup  added 
to  four  tumblers  of  water  (one  quart)  gives  a  solution  1  in  2000.  This 
strong  solution  contains  5|  grains  of  corrosive  sublimate  and  3  grains 
common  salt  to  a  drachm  of  water. 

It  may  be  ordered  thus  : 

R.         Lotion.  Hydrarg.  Perchlor.  §v. 

(5f  grs.  of  Hydrarg.  Perchlor.,  and  3  grs. 
of  Sod.  Chlorid.  to  1  drachm  of  water). 
To  be  put  in  a  special  bottle  with  cupped  stopper. 
Sig.  Poison  :  for  external  use. 

Biniodide  of  mercury  is  also  very  effective,  and  is  believed  to  be  better 
than  corrosive  sublimate,  as  it  is  doubly  effective,  and  does  not  form 
insoluble  compounds  nor  corrode  metals  much.  These  antiseptics  can 
also  be  had  as  compressed  pellets  made  up  with  tartaric  acid  in  the  case 
of  the  corrosive  pellets.  These  are  useful  for  the  practitioner,  and 
prevent  mistakes  on  the  part  of  nurses.  Tartaric  acid  should  not  be 
added  to  the  strong  solutions  of  corrosive  as  it  converts  the  latter  into 
calomel  in  about  a  fortnight  (Dott). 

For  cleansing  the  operator's  hands  or  the  part  to  be  operated  on,  or  as  a 
douche  for  a  wound,  it  is  very  valuable.  It  is  best  used  with  a  glass  vaginal 
pipe.  In  regard  to  the  many  other  antiseptics,  we  need  only  mention 
boracic  acid  (1  in  30)  and  thymol  (1  in  2000)  as  serviceable.  Hydro- 
naphthol  (1  in  2000)  is  a  new  antiseptic  which  is  being  largely  used 
owing  to  its  being  non-poisonous  and  non-irritating. 

lodoform  and  other  agents  will  be  referred  to  as  occasions  for  their 
use  arise. 

Antiseptics  The  following  general  directions  should  be  attended  to.  The  operative 
™  Gynecologist  must  be  most  careful  in  his  attention  to  the  surroundings  of 
his  patient.  The  room  must  be  airy,  well  lighted,  and  well  ventilated ; 
and  the  drainage  of  the  house  must  be  perfect.  The  nurse  in  attendance 
must  know  the  principles  of  antiseptics,  and  the  great  importance  of 
cleanliness  in  her  person. 

The  Sponges  should  be  always  most  carefully  looked  to.  After  each 
operation  they  should  be  thoroughly  washed  in  very  hot  water,  and  then 


ANTISEPTICS.  151 

dried.  During  the  operation,  they  are  to  be  wrung  out  of  1-40  carbolic 
lotion.  Care  should  be  taken  that  they  do  not  become  friable. 

Instruments  should  be  kept  clean,  and  during  an  operation  laid  in 
shallow  trays  containing  1-40  carbolic  lotion.  The  operator  must  always 
prior  to  an  operation  cleanse  his  hands  thoroughly  with  1-2000  corrosive 
sublimate ;  nor  should  he  recently  have  performed  post-mortems  or 
touched  cases  of  erysipelas.  Finger  nails  are  to  be  kept  short  and  the 
nail  brush  scrupulously  used.  Asepticity  of  fingers  or  instruments 
can  be  tested  by  touching  a  sterilized  gelatine  plate  with  them  after 
purification  with  corrosive  sublimate.  It  can  then  be  noted  if  any 
growth  of  micro-organisms  happens.  This  might  be  done  by  a  practi- 
tioner who  suspects  he  is  carrying  contagion. 

The  part  to  be  operated  on,  if  skin,  should  be  cleansed  with  turpentine 
and  then  with  corrosive  sublimate  1  in  2000.  For  unbroken  mucous 
surfaces,  a  douche  of  1  in  2000  is  sufficient. 

During  perineal,  vaginal,  and  cervical  operations  a  douche  of  boracic 
lotion  (1-30)  or  carbolic  lotion  (1-40)  should  play  on  the  part.  This 
not  only  has  an  antiseptic  value,  but  by  washing  away  all  blood  at  once 
gives  a  good  view  of  parts  to  the  operator. 

Antiseptics  must  be  used  with  intelligence.  The  too  diligent  use  of 
strong  antiseptics  may  lead  to  poisoning ;  as  has  occurred  with  carbolic 
acid,  corrosive  sublimate,  or  iodoform.  With  ordinary  precautions,  this 
will  be  rare. 

All  wound  discharges  should  be  received  into  antiseptic  media  such  as 
carbolic  gauze,  salicylic  wool,  or  sublimated  wood-wool  wadding. 

All  that  has  been  said  has  to  do  with  the  destruction  of  micro-organ- 
isms outside  the  body,  and  is  therefore  only  prophylactic.  When  once 
they  have  gained  access  to  the  tissues,  our  power  of  destroying  them  is 
at  present  nil.  All  we  can  then  do  is  to  prevent  their  further  entrance, 
and  enable  the  patient's  constitution  to  resist  them. 

From  what  has  been  said  as  to  antiseptics  it  is  evident  that  an 
effective,  non-decomposable  and  non-poisonous  antiseptic  has  still  to  be 
discovered. 


PART    II. 

DISEASES  OF  THE  FEMALE  PELVIC  ORGANS. 

TTTE  classify  the  diseases  of  the  female  pelvic  organs  according  to  the 
structure  which  is  affected,  and  devote  one  section  to  each  group 
of  affections  as  follows  : — 

Section  III.  The  Peritoneum  and  Connective  Tissue; 
,,        IV.  The  Fallopian  Tubes  and  Ovaries; 
„         V.  The  Uterus ; 
„       VI.  The  Vagina; 
„      VII.  The  Vulva  and  the  Pelvic  Floor. 

Further,  we  shall  consider  under  special  sections  disturbances  of  the 
following  functions : — 

Section  VIII.   The  Menstrual  function  ; 
,,         IX.  The  Reproductive  function. 

Finally,  we  shall  devote  one  section  to  affections  of  the  other  pelvic 
organs  : — 

Section  X.  The  Bladder  and  the  Rectum. 

In  an  Appendix  there  will  be  specially  treated  Abdominal  Section, 
Electricity  in  Gynecology,  the  Systematic  Treatment  of  Nerve  Prostra- 
tion, Hysteria,  Case-taking,  and  Gynecological  Literature. 


SECTION  III. 

AFFECTIONS  OF  PERITONEUM  AND  CONNECTIVE 
TISSUE. 

CHAPTER  XVII.  Pelvic  Peritonitis  and  Pelvic  Cellulitis  (Parametritis). 
„      XVIII.  Pelvic  Hsematocele  and  Heematoma :  New  Growths  in 
the  Pelvic  Peritoneum  and  Connective  Tissue. 


CHAPTER  XVII. 

PELVIC  PERITONITIS  AND  PELVIC  CELLULITIS 
(PARAMETBITIS). 

LITERA  TURS. 

Bandl—Die  Krankheiten  der  Tuben,  etc.  :  Billroth's  Handbuch,  Stuttgart.     Barnes— 
Diseases  of  Women  :  London,  1878.     Bernutz  and  Goupil — Clinical  Memoirs  of  the 
Diseases  of  Women,  Vol.  II. :  New  Sydenham  Society,  Meadow's  translation,  1866. 
Churchill— On  Inflammation  and  Abscess  of  the  Uterine  Appendages :  Dub.  J.  of 
Med.  Sc. ,  1843.    Doherty—On  Chronic  Inflammation  of  the  Uterine  Appendages  after 
Childbirth  :  Dub.  J.  of  Med.  Sc.,  1843.     Duncan,  J.  Matthews— A  Practical  Treatise 
on  Perimetritis  and  Parametritis  :  Edinburgh,  A.  &  C.  Black,  1869.     On  Albuminuria 
with  Parametritis:  Lond.  Eoy.  Med.  and  Chir.  Tr.,  Vol.  LXVII.    Freund,  W.  A.— 
Anatomische  Lehrmittel,  etc. :  Gesellschaft  f.  Geburtshiilfe,  Berlin,  Band  iv.  Hft.  1. 
Das  Bindegewebe  im  weiblichen  Becken  und  seine  pathologische  Veranderungen,  etc. ; 
Gynakologische  Klinik,  Strassburg,  1885.       Freund,   H.    W. — Ueber  die  feineren 
Veranderungen  der  Nervenapparate  im  Parametrium  bei  einfacher  und  parametri- 
tischer  Atrophie :   Cent.  f.  Gyn.,  IX.  S.  644.      Heitzmann — Die  Entziindung  des 
Beckenbauchfells  beim  Weibe  :   Wien,  1883.      Lusk — Puerperal  Fever :   Internat. 
Cong.  Trans.,   1877.       MacDonald,  Angus— Three    Cases  of  Parametritis,   with 
observations  on  its  Diagnosis  and  Treatment :  Ed.  Med.  J.,  1880,  p.  1060.     Mundt, 
P.  F. — The  Diagnosis  and  Treatment  of  Obscure  Pelvic  Abscess  in  Women,  with 
remarks  on  the  differential  Diagnosis  between  Pelvic  Peritonitis  and  Pelvic  Cellu- 
litis :  Archives  of  Medicine   (E.  C.  Seguin,  Ed.),  Vol.  IV.,  No.  3.     Noeggerath — 
Latent  Gonorrhoea  especially  with  regard  to  its  influence  on  Fertility  in  Women  : 
Am.  Gyn.  Tr.,  Vol.  I.     Olshauscn — On  Puerperal  Parametritis  and  Perimetritis: 
New   Syd.    Soc.   Transl.,  1876.    Priestley,    W.   0.—  Pelvic  Cellulitis    and   Pelvic 
Peritonitis :    Reynold's   System    of    Medicine,   Vol.  V.       Schroedei — Krankheiten 
der  weiblich.  Geschlectsorgane  :  Leipzig,  1879.     Schultze,  B.  S. — Ueber  die  patho- 
logische Anteflexion  der  Gebarmutter  und  die  Parametritis  posterior  :  Hirschwald, 
Berlin,    1875.      De  Sintty— Gynecologic :   Paris  1879.      Simpson,   Sir  J.    F.— On 
Pelvic  Cellulitis  and  Pelvic  Peritonitis,  Clinical  Lectures  on  the  Diseases  of  Women 
(edited  by  A.  E.  Simpson) :  Edinburgh,  A.  &  C.  Black,  1872.    Simpson,  A.  E.— 
Quarterly  Report  of  the  Royal  Maternity  and  Simpson  Memorial  Hospital :  Ed.  Med. 
Journal,  Vol.  XXVI.,  p.  1059.     Spiegelbery — Remarks  upon  Exudations  in  the  Neigh- 
bourhood of  the  Female  Genital  Organs  :  Second  Series  of  German  Clinical  Lectures, 
Translated  by  New  Sydenham  Society,  1877.     Tait,  Lawson—On  the  Treatment  of 
Pelvic  Suppuration  by  Abdominal  Section  and  Drainage  :  Tr.  of  Lond.  Roy.  Med.  and 
Chi.  Soc.,  1880,  p.  307.     Williams,  John— Serous  Perimetritis :  Lond.  Obstet.  Trans., 
1885.     Winckcl— Die  Pathologic  der  weiblichen  Sexual-organe  :  Leipzig,  1881.     This 
lastgives  photo-lithographs  of  great  value.    Ziegler — A  Text-book  of  Pathological  Ana- 
tomy and  Pathogenesis,  Macalister's  translation  :  London,  Macmillan  and  Co.,  1883. 
See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

Peritonitis.  IN  treating  of  the  subjects  of  pelvic  peritonitis  and  pelvic  cellulitis  it 


PELVIC  PERITONITIS.  157 

will  be  convenient  to  take  up  some  preliminary  matter  and  then  to 
consider  separately  each  condition  under  the  following  heads  : — 

Nature,  Diagnosis  and  differential 

Pathological  anatomy  and  diagnosis, 


varieties, 
Etiology, 
Symptoms, 
Physical  signs, 


Course  and  results, 

Prognosis, 

Treatment. 


Further,  their  effect  on  the  position  of  the  uterus  will  require  special 
consideration. 

Preliminary  considerations, — The  subjects  of  pelvic  peritonitis  andPrelimi- 
pelvic  cellulitis  are  by  no  means  thoroughly  worked  out.  The  literature 
is  extensive,  but  not  so  valuable  as  medical  literature  often  is.  This 
arises  from  various  causes,  among  which  the  most  important  is  the  change 
in  the  theories  as  to  the  anatomical  site  of  pelvic  inflammatory  conditions. 
Nonat  and  Simpson  contended  that  pelvic  peritonitis  and  pelvic  cellulitis 
were  distinct  affections,  and  considered  the  latter  as  being  of  frequent 
occurrence.  Then  Bernutz  and  Goupil  turned  the  tide  for  some  time  by 
their  able  work,  where  they  classed  almost  all  pelvic  inflammatory  affec- 
tions as  peritonitic.  They,  however,  greatly  underrated  the  amount  of 
connective  tissue  surrounding  the  cervix,  as  Guerin  has  more  recently 
done  with  regard  to  the  connective  tissue  of  the  broad  ligaments ;  Le 
Bee  has  endeavoured  to  support  the  opinions  of  the  latter  by  his 
observations  on  the  lymphatic  distribution  of  the  broad  ligaments. 

There  is  now  little  doubt  that  Bernutz  and  Goupil  pushed  their  views 
too  far ;  and  in  America,  Germany,  and  Britain,  gynecologists  now  con- 
sider pelvic  inflammation  as  both  peritonitic  and  cellulitic.  Clinical, 
anatomical,  and  pathological  facts  are  each  day  putting  this  view  on  a 
firmer  basis.  The  fact,  however,  that  these  diseases  are  not  rapidly  fatal, 
and  that  generally  we  get  post-mortems  only  of  advanced  or  resolved 
cases,  along  with  the  admitted  difficulty  of  exact  clinical  differentiation, 
renders  our  knowledge  much  less  complete  and  exact  than  could  be 
wished. 

Finally,  we  must  note  that  both  diseases  are  almost  always  combined. 
Thus  in  a  marked  pelvic  peritonitis  there  is  always  some  pelvic  cellulitis, 
and  in  a  marked  pelvic  cellulitis  always  some  pelvic  peritonitis.  This 
is  quite  analogous  to  what  is  found  in  pleurisy  and  pneumonia. 

PELVIC    PERITONITIS. 

SYNONYMS. — Perimetritis  :  Pelveo-peritonitis. 

NATURE. — An  acute  or  chronic  inflammatory  condition  affecting 
chiefly  the  pelvic  peritoneum. 


158          PERITONEUM  AND  CONNECTIVE  TISSUE. 

PATHOLOGICAL    ANATOMY    AND    VARIETIES. 

Patholo-         In  the  early  stages,  the  peritoneum  is  injected  and  the  epithelial  cells 

#ical          dull  jn  iustre.     Soon,  in  marked  cases,  fibrinous  or  serous  fluid  is  poured 

''  out:   the  former  stiffens  the  peritoneum  and   often  causes  extensive 

adhesions  between  uterus  and  rectum,  Fallopian  tubes  and  ovary  ;  the 

latter  either  remains  free  in  the  cavity,  or  becomes  encysted  by  the 

false  membranes  already  alluded  to,  often  making  Douglas'  pouch  to 

bulge  down.     In  bad  cases,  pus  is  formed.     We  may  therefore  speak 

Varieties,    of  simple  pelvic  peritonitis,  adhesive  pelvic  peritonitis,  and  serous  or 

purulent    pelvic    peritonitis.     These,    however,    are    mere    varieties. 

Tubercular  and  malignant  peritonitis  will  be  considered  by  themselves. 

ETIOLOGY. 

Etiology.        The  causes  of  pelvic  peritonitis  are  numerous.     They  are  chiefly  the 
following. 

1.  The    existence    of    pelvic     cellulitis,    pelvic 

ovaritis,    ovarian   tumour,    fibroid  tumour, 
carcinoma. 

2.  Childbirth  and  abortion. 

3.  Gonorrhoea. 

4.  Latent  gonorrhoea  in  the  male. 

5.  A  chill,  especially  during  menstruation. 

6.  Venereal  excess. 

7.  Instrumental   examination  by  the  sound ;   stem   pessaries, 

sponge  or  tangle  tents. 

8.  Tubal  disease. 

1.  The  existence  of  pelvic  cellulitis,  pelvic  hcematocele,  ovaritis,  ovarian 
tumour,  fibroid  tumour,  tubercle,  or  carcinoma,. 

We  have  already  noted  that  marked  pelvic  cellulitis  is  always  associ- 
ated with  some  pelvic  peritonitis.  The  pelvic  peritoneum  and  cellular 
tissue  are  adjacent  and  intimately  connected  with  one  another  in  their 
vascular,  nervous,  and  especially  in  their  lymphatic  supply ;  we  have 
already  seen  how  the  stomata  of  the  peritoneum  communicate  with 
subendothelial  lymphatics.  In  the  same  way  we  can  understand  a 
pelvic  peritonitis  arising  secondarily  from  ovaritis.  A  hsematocele  is 
always  followed  by  inflammatory  changes  in  the  peritoneum. 

Ovarian  tumours  often  set  up  pelvic  peritonitis  after  being  tapped  as 
well  as  from  their  mere  mechanical  pressure  or  from  torsion  of  their 
pedicle — a  fact  of  the  highest  importance  as  regards  the  operation  of 
ovariotomy.  Occasionally  we  get  general  peritonitis  from  suppuration 
of  a  small  ovarian  tumour  and  its  perforation  with  escape  of  pus  into 
the  peritoneal  cavity.  Small  fibroids,  tubercle,  and  cancer  do  the 
same,  and  thus  give  rise  to  considerable  difficulty  in  diagnosis.  Foulis 


PELVIC  PERITONITIS.  159 

of  Edinburgh  has  thrown  much  light  on  malignant  peritonitis,  by 
showing  that  in  the  ascitic  fluid  we  find  very  characteristic  cell  clusters. 
This  will  again  be  referred  to  under  ovarian  tumour. 

2.  Childbirth  and  abortion.     When  an  inflammatory   lesion  follows 
these,  it  is  generally  cellulitic  and,  as  we  shall  afterwards  see,  probably 
septic.     Pelvic  peritonitis  often  enough  follows,  and  is  then  probably 
likewise    septic.       According   to    Lusk,    who    quotes    Steurer's    unpub- 
lished researches,   "bacteria  pass  along  the  lymphatics  .  .   .  and  per- 
forating those  beneath  the  peritoneum  set  up  pyaemic  peritonitis."    At  the 
same  time,  the  peritonitis  may  result  from  simple  bruising. 

3.  Gonorrhoea  is  one  great  cause  of  peritonitis.     It  may  result  from 
actual  spread  of  the  gonorrhoeal  virus  ;  or  be  sympathetic,  like  orchitis  in 
the  male.     In  the  former  case  the  purulent  infection  probably  passes 
along  the  Fallopian  tubes  and  out  at  the  fimbriated  end,  setting  up  a 
severe    peritonitis.       In  puerperal  women,  gonorrhoea  is  by  no  means 
innocent,  as  the  following  case  by  A.  R.  Simpson  shows : — 

"  J.  C.,  primipara,  prostitute,  set.  18,  was  admitted  to  the  hospital  and 
delivered  of  a  male  child.  On  the  afternoon  following,  severe  peritonitis 
set  in  which  proved  fatal  in  ten  days.  On  post-mortem  the  abdomen 
contained  5  viii.  of  yellow  pus.  Surface  of  intestines  covered  Avith  recent 
nbrinous  lymph  becoming  purulent.  Mucous  membrane  of  bladder  much 
congested  and  in  certain  areas  rough  and  granular.  .  .  .  On  squeez- 
ing the  Fallopian  tubes  a  large  quantity  of  pus  was  expelled,  and  the 
tubes  appeared  to  be  much  distended  with  it.  Mucous  membrane  much 
congested."  (Report  by  D.  J.  Hamilton.) 

4.  Latent  gonorrhoea  in  the  male. — By  this  term  Noeggerath  of  New 
York,  who  first  directed  attention  to  the  subject,  means  a  gonorrhoea  in 
the  male  apparently  cured,  which  some  time  after — even  two  years — 
infects  a  healthy  genital  tract,  causing  discharge  and  pelvic  peritonitic 
disturbance.      The  authors  have  seen  some  cases  bearing  out  Noeg- 
gerath's  views. 

5.  Chill,  especially  during  menstruation. — It  can  be  readily  understood 
how  the  pelvic  congestion  of  menstruation  may  under  undue  exposure 
to  cold  pass  into  peritonitis. 

6.  Venereal  excess  in  prostitutes  and  newly  married  women  may,  for 
evident  reasons,  have  peritonitis  as  its  sequel,  although  exact  proof  of 
this  is  difficult. 

7.  Instrumental  manipulation. — This  is  alluded  to  under  the  various 
instruments  and  needs  mere  mention  here. 

8.  Tubal  disease. — This  is  now  recognised  as  an  important  cause  of 
pelvic    peritonitis,   and   has    been  above    alluded  to  under  Gonorrhoea. 
The  facts   that   the    genital  tract    communicates   with   the   peritoneal 
cavity  through  the  Fallopian  tubes,   and  that  gonorrhoea  and  septic 
-diseases    are    due    to    micro  -  organisms,    explain,    in   many   instances, 


160  PERITONEUM  AND  CONNECTIVE  TISSUE. 

the  causation  of  peritonitis.  Tubal  disease  and  peritonitis  are  mutually 
related,  inasmuch  as  occlusion  of  the  tube  may  be  set  up  after  the  peri- 
tonitis and  thus  tubal  distention  follow.  Gonorrhoeal  pus  sets  up  limited 
peritonitis,  the  explanation  given  being  that  the  gonococcus,  its  specific 
organism,  does  not  flourish  on  squamous  as  it  does  on  cylindrical 
epithelium.  The  micrococci  found  in  septic  pus  on  the  other  hand  set 
up  violent  peritonitis  when  introduced  into  the  peritoneal  cavity. 
Bernutz's  We  append  Bernutz's  analysis  of  the  causes  of  pelvic  peritonitis  in 

Analysis. 

ninety-nine  cases. 

43  occurred  in  puerperse. 

28        „       after  gonorrhoea. 

20        ,,       during  menstruation. 

'3  due  to  venereal  excess. 


.12  ,,  syphilitic  diseases  of  cervix. 
2  „  introduction  of  the  ute~:~~ 
1  use  of  vaginal  douche. 


8  traumatic<  _  c  , , 

i  2        „      introduction  of  the  uterine  sound. 


SYMPTOMS  AND  PHYSICAL  SIGNS. 

A.  Acute  Peritonitis. 

Symptoms.  Symptoms.  Increased,  full,  and  bounding  pulse ;  increased  tempera- 
ture ;  rigor ;  shooting  pains  very  severe. 

Physical  Physical  Signs.  On  palpation  of  lower  part  of  abdomen  the  patient 
complains  of  pain  ;  and  the  abdominal  muscles,  apart  from  the  patient's 
volition,  resist  pressure.  She  lies  usually  on  the  back,  and  with  both 
legs  drawn  up. 

On  vaginal  examination  the  vagina  feels  hot  and  tender,  and  pulsating 
vessels  may  be  felt  in  the  fornices. 

After  exudation  is  present,  we  may  feel  one  or  other  of  the  following 
conditions. 

1.  A  flat  hard  non-bulging  condition  of  the  fornices  round  the  cervix, 
which  is  not  displaced  to  one  or  other  side  but  is  immobile.     The  usual 
simile,  and  a  very  good  one,  is  that  it  feels  as  if  plaster  of  Paris  had  been 
poured  into  the  pelvis. 

2.  An  indistinct  fulness  high  up  in  the  pelvis.      This  is  from  free 
serous  exudation. 

3.  A  bulging  tumour  behind  the  uterus  displacing  it  to  the  front ;  or 
a  tense  fluid  laterally,  apparently  in  the   site  of  the   broad   ligament 
(fig.  43). 

The  former  is  due  to  encysted  serous  effusion  in  the  pouch  of  Douglas, 
the  latter  to  encysted  serous  fluid  behind  the  broad  ligaments  displacing 
it  forwards.  As  a  general  rule  these  effusions  are  high  in  the  pelvis  and 
symmetrical.  Sometimes  the  bulging  retro-uterine  tumour  feels  nodulated 
after  a  time  ;  this  is  from  extension  of  the  inflammatory  condition  into  the 
subjacent  connective  tissue. 


PELVIC  PERITONITIS.  161 

Note  that  the  Bimanual  is  often  impossible  owing  to  the  rigid  condition 
of  the  fornices  and  abdominal  muscles.  The  bimanual  estimation  of 
effusion  is  often  misleading  owing  to  the  fact  that  we  feel  the  rigid 
peritoneal  membrane  through  the  fornices,  and  from  the  rigidity  of  the 
abdominal  wall  draw  the  conclusion  that  there  is  effusion  between.  Careful 
examination  under  chloroform  is  of  the  highest  value  in  such  cases. 

B.  Chronic  Peritonitis. 

Symptoms.     These   are   chiefly  backache,    sideache,    leucorrhoea,    in- Symptoms, 
creased  menstruation  and  sterility.     Pain  is  the  most  marked  symptom, 
and  is  felt  most  on  vaginal  examination  or  coitus. 

Physical  Signs.     On  vaginal  examination,  obscure  thickening  is  felt  in  Physical 
the  fornices.     The  uterus,  if  displaced,  is  often  markedly  anteverted  from 


FIG.  113. 

PERITONEAL  BANDS  binding  down  the  Uterus,  Tubes,  and  Ovaries— result  of  chronic  pelvic 
peritonitis  (Heitzmann). 

cicatrisation  of  the  peritoneum  in  the  pouch  of  Douglas.  Very  frequently 
it  is  retroverted  and  bound  down  by  adhesions,  which  may,  however, 
allow  of  a  certain  range  of  mobility. 

The  chronic  form  may  occur  as  a  sequel  to  the  acute ;  most  frequently 
it  develops  slowly  of  itself. 

DIFFERENTIAL  DIAGNOSIS. 

This  will  be  considered  under  Cellulitis. 

COURSE  AND  RESULTS. 

Very  often  the  inflammatory  condition  clears  up.     The  adhesive  form  Course  and 

Results. 


1C2          PERITONEUM  AND  CONNECTIVE  TISSUE. 

leaves  its  mark  in  the  shape  of  pathological  anteversions,  and  retro- 
versions  bound  down  (*.  figs.  113,  114).  The  Fallopian  tubes  may  have 
their  ovum-conducting  power  so  interfered  with  that  an  incurable  sterility 
results  When  they  are  not  injured  to  this  extent,  conception  may  occur ; 
and  the  adhesions  may  ultimately  yield  to  the  stretching  brought  to  bear 
on  them  by  the  developing  uterus.  They  may,  however,  resist  this  and 

cause  abortion. 

Occasionally,  pelvic  peritonitis  becomes  general  and  is  then  rapidly 
fatal.  Serous  exudations  may  become  absorbed  ;  pus  may  be  absorbed, 
but  oftener  perforates  into  the  bladder,  bowel,  or  vagina. 


PROGNOSIS. 

Prognosis.       Each  case  must  be  judged  on  its  own  merits. 
only  general  hints. 


We  give,  therefore, 


FIG.  114. 

UTERUS  retroverted  and  bound  back  by  peritonitic  adhesions  (WinckeV).     a  a  adhesions  ;  I  bladder  ; 
v  vagina ;  u  uterus ;  r  rectum.  (|) 

As  to  life. — Pelvic  peritonitis  is  not  usually  fatal.  If  it  becomes 
general  and  is  septic  or  gonorrhoea!  in  its  origin,  then  the  prog- 
nosis is  very  grave.  A  high  and  rapid  pulse  of  long  continuance, 
with  a  temperature  not  in  the  same  ratio,  also  makes  prognosis 
grave. 

As  to  sterility. — This  is  difficult  to  give,  and  often  time  alone  settles 
the  point.  The  mechanical  closure  by  pressure  of  the  Fallopian  tube — 
a  condition  not  diagnosable — and  ovaritis  rendering  ovulation  impossible, 
are  conditions  often  produced  and  both  incurable.  Prognosis  as  to 
conception  should  always  be  cautious,  and  never  absolute  when  the 
peritonitis  has  been  extensive. 


PELVIC  PERITONITIS.  163 

TREATMENT. 

A.  Acute  pelvic  peritonitis. — a.  Prophylactic.  Treat- 

b.  General.     (1.)  Diet.  (2.)  Septicity.  (3.)ment' 

Pain.       (4.)  Pulse  and  Temperature. 

c.  Local. 

a.  Prophylactic. — This    is    of   the    very  highest    importance.       Theprophy 
practitioner  should  always  attend  most  scrupulously  to  antiseptic  clean- j^*^ 
liness  in  all  vaginal,  cervical,  and  uterine  operations.     Cautions  on  these  ment. 
points  have  been  already  given  in  Chap.  XVI.  and  will  be  referred  to  again 
under  the  respective  operations. 

During  the  menstrual  period  young  patients  should  avoid  all  undue 
fatigue,  late  hours,  violent  exercise,  alternate  exposure  to  heat  and  cold 
when  insufficiently  clad. 

Gonorrhoea  should  be  thoroughly  treated,  especially  during  pregnancy. 

b.  General. — -Under  this  we   attend  to  diet;   and  employ  remedies  General 
intended  to  combat  the  septic  condition  when  present,  to  alleviate  pain,  m^t " 
and  to  bring  down  pulse  and  temperature. 

(1.)  Diet. — In  the  early  stages  of  inflammation,  this  should  be  chiefly  Diet, 
milk,  iced  or  mixed  with  lime  water  or  potash  water  or  lemonade.    Among 
the  better  classes,  apollinaris  or  seltzer  water  can  be  used.     Seltzer  water 
helps  to  combat  the  constipating  tendency  of  milk  diet. 

When  the  patient's  strength  is  reduced  and  the  pulse  flagging,  nutri-  stimu- 
tious  stimulating  food  must  be  frequently  given.     Milk  should  be  still      ts' 
continued  ;  but  beef  tea  or  strong  soups  every  two  or  three  hours  must 
be  added.     Stimulants  are  requisite  at  this  stage,  viz.,  brandy,  cham- 
pagne, gin,  or  whisky.      Care  must  be  taken  to  give   these  in   their 
stimulating  doses,  e.g.,  for  brandy,  a  table-spoonful  every  two  or  three 
hours. 

The  regulation  of  the  bowels  is  not  requisite  in  the  early  stages  ;  but  Regulation 
in  the  later  periods  must  be  looked  after.  Gentle  aperients  such  as 
compound  liquorice  powder,  colocynth  and  hyoscyamus  pills,  castor  oil, 
etc.,  can  be  used ;  and  occasional  enemata  are  of  service.  Enemata  should 
not,  however,  be  used  exclusively,  as  that  might  lead  to  the  formation  of 
troublesome  scybala. 

When  suppuration  is  tedious,  it  should  be  seen  that  no  bed  sores  form ;  Tonics, 
and  iron  and  quinine  should  be  administered. 

5L  Ferri  et  Quininse  Citratis         gr.  Ixxx. 

Aquse  gij. 

Sig.  Teaspoonful  thrice  daily  in  water. 

or 
R.  Ferri  et  Ammonii  Citratis        gr.  Ixxx. 

Aquse  gij. 

Sig.  Teaspoonful  thrice  daily  in  water. 


164          PERITONEUM  AND  CONNECTIVE  TISSUE. 

The  bitterness  is  best  masked  by  dilution  with  water  and  not  with 
orange  or  other  syrups  which  derange  the  stomach. 

Treatment       (2.)  To  combat  any  septic  condition.— We  know  no  specific  medicine 
sf I'if       for  this  purpose.     A  favourite  one  is  the  muriate  of  iron  of  the  Ed. 
Phar. 

R.   Tincturse  Ferri  Muriatis  (Ed.  Phar.)          gij. 
Sig.  Thirty  drops  thrice  daily  in  a  glass  of  water.     Water 
should  be  drunk  freely  after  the  dose  is  given,  and  the 
mouth  thoroughly  rinsed  with  bicarbonate  of  soda  and 
water. 
Quinine  may  be  used  for  the  same  purpose. 

R.  Quininse  Sulphatis  gr.  xxxvl 

Acidi  Sulphurici  diluti  3JJ- 

Aquam  ad  §vj. 

Sig.  Tablespoonful  thrice  daily  in  water. 

Treatment       (3.)  To  alleviate  pain. — Nothing  is  so  good  for  this  as  the  hypodermic 
un'      injection  of  morphia. 

R.  Morphinse  Bimeconatis  gr.  viij. 
Spiritus  Vini  Rectificati  miiij. 

Aquae  5J. 

Sig.  For  Hypodermic  injection.  Fifteen  minims  contain 
i  grain  of  Morphia. 

The  bimeconate  is  a  good  preparation  and  causes  less  sickness  than 
other  forms ;  as  one  drachm  of  this  preparation  contains  one  grain  of 
morphia,  and  as  the  hypodermic  syringe  holds  only  30  min.,  it  is  impos- 
sible to  give  an  overdose  to  an  adult. 

When  doses  larger  than  half-a-grain  are  needed,  the  hypodermic  solution 
of  the  acetate  of  morphia  (B.  P.)  may  be  employed.  Twelve  minims 
contain  1  grain,  and  therefore  3  minims  is  the  first  dose  for  an 
adult 

It  is  a  good  plan  for  the  practitioner  to  keep  the  ordinary  8  gr.  to  §i. 
solution,  and  to  prescribe  the  stronger  solution  only  for  any  patient 
requiring  it;  in  this  way  he  avoids  carrying  two  solutions  of  different 
strength  by  which  mistakes  might  arise.1  The  stronger  solution  is  pre- 
scribed as  follows  : — 

R.  Injectionis  Morphinae  Hypodermicse  (B.  P.)  3ij. 

Sig.  For  Hypodermic  injection.     Ten  minims  contain  1  grain 
Acetate  of  Morphia.     Dose,  1  to  5  minims. 

Chlorodyne  (25  min.);   Battley's  solution   (liquor  opii  sedativus,  15 

1  Morphia  is  also  made  up  in  compressed  Hypodermic  Tabloids,  containing  various  doses.  They 
are  readily  dissolved  in  a  few  drops  of  water,  and  are  both  reliable  and  portable. 


PELVIC  PERITONITIS.  165 

min.)  or  laudanum  (tinctura  opii,  25  min.)  may  be  used.     More  useful 
than  these  are  morphia  suppositories. 

R.  Morphinse  Hydrochloratis  gr.  ^ 

Fiat  Suppositorium  Mitte  tales  vj. 

Sig.  As  directed. 

It  is  a  good  plan  to  quiet  the  pain  rapidly  with  the  hypodermic  injec- 
tion ;  and  to  keep  up  the  good  effect  by  suppository,  in  ^  grain  doses 
every  six  hours,  beginning  6  to  8  hours  afterwards.  See  that  the  patient 
or  attendant  understands  that  the  suppositories  are  to  be  passed  into  the 
empty  bowel. 

(4.)  To  bring  down  pulse  and  temperature — In  early  stages,  tincture  of  Treatment 
aconite  is  invaluable.  Pulsefand 

R.  Tincturse  Aconiti  3ij.  Tempera- 

Sig.  Six  drops  are  to  be  put  in  a  wine  glass  containing  six 
teaspoonfuls  of  water.  Give  a  teaspoonful  every 
quarter  of  an  hour. 

Drop  doses  of  aconite  are  of  great  value.  They  should  be  given  every 
quarter  of  a  hour  until  the  pulse  is  reduced  and  sweating  brought  on. 

If  the  temperature  still  keep  high,  quinine  in  15  grain  doses  may  be 
given.  The  salicylate  of  quinine  is  a  good  preparation  and  is  given  just 
as  quinine  is.  When  the  stomach  is  irritable  the  quinine,  in  20  grain 
doses,  suspended  in  an  ounce  of  mucilage,  may  be  given  per  rectum. 

Antipyrin  (10-15  grains)  and  antifebrin  (5-10  grains)  are  useful.  The 
former  also  aids  in  headache,  but  the  latter  tends  to  produce  cyanosis 
and  though  very  effective  requires  to  be  watched  for  undue  depression. 
Alcohol  may  be  given  with  it  (v.  Leech,  Med.  Chron.,  Vol.  VIII. 
p.  297). 

After  the  fever  has  subsided  and  suppuration  threatens,  the  strength 
must  be  kept  up  by  tonics  (such  as  quinine  and  iron)  and  by  nutritious 
food  with  a  judicious  amount  of  stimulant,  claret  for  example. 

c.  Local  Treatment.     In  the  early  stages  of  sthenic  nonseptic  cases,  Local 
8-10  leeches  may  be  applied  over  the  iliac  regions.  Treat- 

Ice  is  not  generally  used  as  a  local  application  in  this  country,  and  has 
its  disadvantages. 

Of  greater  use  are  large  hot  linseed  poultices.  They  should  be  made 
very  hot,  a  layer  of  flannel  intervening  between  them  and  the  skin,  and 
should  be  covered  with  a  layer  or  two  of  cotton.  Such  a  poultice  will  be 
effective  for  2  or  3  hours.  Blisters  and  turpentine  stupes  are  good,  but 
soon  render  the  skin  so  sore  that  after-treatment  by  poultices  is  difficult. 

The  hot  vaginal  douche  (as  directed  at  page  138),  with  carbolic  acid 
added  in  septic  cases,  should  on  no  account  be  omitted. 

Encysted  serous  collections  should,  as  a  general  rule,  be  left  to  be 
absorbed.  When  troublesome  from  pressure,  they  may  be  tapped  by 
Matthieu's  aspirator.  A  clear  serous  fluid,  often  coagulable,  is  then 


166  PERITONEUM  AND  CONNECTIVE  TISSUE. 

drawn  off,  so  like  urine  that  the  almost  involuntary  first  thought  is  that 
the  operator  has  tapped  the  bladder  by  mistake. 

Pus  does  not  form  very  often  in  pelvic  peritonitis.  It  may  perforate 
into  the  rectum  or  through  the  posterior  fornix.  The  treatment  of  sup- 
puration will  be  best  considered  under  pelvic  cellulitis,  but  we  may 
state  here  that  abdominal  section  and  drainage  may  be  required  in  sup- 
purative  peritonitis  and  in  cases  due  to  suppuration  of  an  ovarian  cyst 
with  perforation. 

Treatment  /?.  Treatment  of  chronic  pelvic  peritonitis. — When  adhesions  are 
Chronic,  extensive,  the  case  is  better  left  alone.  When  the  uterus  is  retroverted, 
it  may  ultimately  be  replaced  by  bimanual  manipulation.  Massage  is 
good  in  such  cases,  but  its  employment  will  be  considered  afterwards 
when  we  speak  of  the  systematic  treatment  by  rest  and  food 
(v.  Appendix). 

Of  late,  since  our  knowledge  of  the  nature  of  tubercle  has  been 
rendered  more  exact  by  Koch's  discovery  of  the  tubercle  bacillus,  tuber- 
cular peritonitis  has  been  found  to  be  by  no  means  rare  ;  and  the  bacillus 
tuberculosis  has  now  been  discovered,  sparingly  and  in  giant  cells,  by 
several  observers.  We  may  also  have  malignant  peritonitis,  due  usually 
to  rupture  of  papillomatous  ovarian  cysts.  In  both  the  tubercular  and 
the  malignant  form  we  get  ascitic  fluid,  but  characteristic  cells  in  the 
latter  only. 

TUBERCULAR   PERITONITIS. 

LITERATURE.  Hegar—Die  Entstehung,  Diagnose  und  chirurgische  Behandlung  der 
Genitaltuberculose  des  Weibes  :  Stuttgart,  Enke,  1886.  Poten—  Ein  Fall  geheilter 
Bauchfelltuberculose :  Cent,  fur  Gyn.,  1887,  S.  33.  Schwarz— Ueber  die  palliative 
Incision  bei  Peritonitis  tuberculosa  :  Wien.  Med.  Wochens.,  No.  13,  1887.  Tuit, 
Lawson— Diseases  of  the  Ovaries,  fourth  edit.,  p.  334  :  Birmingham,  1883.  Wells, 
Sir  T.  £— Ovarian  and  Uterine  Tumours,  p.  100 :  Churchill,  London,  1882.  For 
history  and  further  literature  see  Schwarz,  or  Cassel's  Year  Book  for  1888.  See  also 
Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

Preliminary  Jtemarks.—The  serious  results  of  tubercular  disease  of  the 
lungs,  meninges,  and  mucous  tracts,  render  the  comparatively  good  prog- 
nosis in  tubercular  peritonitis  as  remarkable  as  it  is  at  present  inexplic- 
able. In  Wells'  historical  case  in  1862,  abdominal  section  was  performed 
for  ascites  due  to  peritoneal  tuberculosis,  miliary  tubercles  were  found 
studding  the  bowel  surface ;  and  yet,  as  the  result  of  the  section  and 
evacuation  of  fluid  only,  complete  recovery  took  place,  the  patient  being 
well  nineteen  years  afterwards  (1881).  Since  then,  equally  good  results 
have  been  obtained  by  others. 

Symptoms.—  The  patient's  general  health  may  be  good,  with  no  rise 
temperature   if  the  peritoneum  alone  is  affected.     It  must  be  kept  in 
mind,  however,  that  the  lungs  may  be  simultaneously  implicated. 


PELVIC  CELLULITIS.  167 

Physical  Signs. — We  may  have  fluid  in  the  abdomen  so  encysted  as  to 
simulate  ovarian  cyst,  or  there  may  be  free  fluid  with  irregular  lumps 
due  to  matting  of  bowels  and  omentum. 

The  Differential  Diagnosis,  which  is  chiefly  from  ovarian  cyst  and 
malignant  peritonitis,  is  difficult  and  may  be  cleared  up  only  by 
exploratory  incision. 

Treatment. — Abdominal  Section,  with  complete  evacuation  of  fluid  and 
careful  peritoneal  toilette  so  as  to  dry  out  as  thoroughly  as  possible, 
is  all  that  is  requisite ;  the  use  of  antiseptic  irrigations  or  the  applica- 
tions of  iodoforni  to  the  peritoneum  before  the  wound  is  closed  has  been 
found  unnecessary,  and  the  same  may  be  said  of  drainage.  In  17  cases 
collected  by  Schwarz,  the  general  age  was  seventeen  to  thirty-three : 
youngest,  four ;  oldest,  fifty-seven.  Immunity  was  found  in  these  to 
range  from  two  to  ten  years,  but  one  case  of  complete  cure  has  been 
recorded  by  Wells.  A  phthisical  condition  of  lung  if  not  too  far 
advanced  is  not  a  centra-indication. 

MALIGNANT    PERITONITIS. 

By  this  we  mean  a  condition  where  the  peritoneum  is  more  or  less 
invaded  by  papillomatous  growths  secondary  usually  to  rupture  of 
papillomatous  cysts  of  the  ovary  (v.  Pathology  of  Ovarian  Tumours, 
Chap.  XXII. ). 

Symptoms. — The  patient  is  not  at  first  cachectic,  and  the  only  thing 
attracting  attention  is  the  distension  of  the  abdomen  from  fluid.  The 
condition  is  not  necessarily  fatal,  and  we  have  seen  one  case  where  the 
patient  lived  for  three  or  four  years.  It  may,  however,  soon  cause  death 
when  pleuritic  or  pericardial  effusions  come  on. 

The  Physical  Signs  are  abdominal  distension,  irregularly  encysted 
fluid,  irregular  masses  felt  in  the  abdominal  cavity  on  palpation,  with 
occasionally  secondary  nodules  in  the  pelvic  or  iliac  glands,  and  charac- 
teristic cell-groups  in  the  fluid  drawn  off.  These  render  diagnosis  fairly 
easy. 

The  Treatment  is  palliative  by  tapping. 

PELVIC  CELLULITIS  (PARAMETRITIS). 

SYNONYM. — Parametritis,  a  term  sometimes  limited  to  inflammation  ofPelvic 
the  cellular  tissue  round  the  cervix  and  upper  part  of  vagina — Virchow's 
parametric  tissue.     At  the  close  of  this  chapter,  we  shall  have  to  notice 
specially  a  variety  of  this  described  by  W.   A.  Freund  as  Parametritis 
chronica  atrophicans  circumscripta  et  diffusa. 

NATURE. — An  acute  or  chronic  inflammatory  affection,  usually  septic, 
affecting  the  cellular  tissue  of  the  pelvis. 


168  PERITONEUM  AND  CONNECTIVE  TISSUE. 

PATHOLOGICAL   ANATOMY    AND    VARIETIES. 

Patho-  it  is  the  rare  exception  to  examine  a  multiparous  female  pelvis  without 

Anatomy    finding  some  trace  of  a  previous  cellulitis  or  peritonitis.      Thus  split 

??d.  cervix,  so  common  in  women  who  have  borne  children,  is  almost  always 

Varieties. 

associated  with  some  cellulitis  at  the  base  of  the  broad  ligaments.  The 
uterus  is  rarely  central,  but  is  often  drawn  to  the  one  side  by  the 
cicatrisation  of  some  previous  lateral  cellulitic  inflammation  of  the 
broad  ligament ;  the  traction  may  even  be  so  great  that  it  lies  at  right 
angles  to  its  proper  axis.  We  have  seen  that  the  utero-sacral  ligaments 
are  peritoneal  folds  containing  connective  tissue  and  unstriped  muscular 
fibre.  Inflammatory  attacks  in  one  or  both  of  these  folds  (combined 
pelvic  peritonitis  and  pelvic  cellulitis)  are  very  common.  Schultze 
calls  this  "  parametritis  posterior,"  but  utero-sacral  cellulitis  is  a  more 
accurate  term.  The  cicatrisation  of  these  ligaments  after  such  inflam- 
mation, causing  traction  just  above  the  isthmus,  brings  about  the  most 
common  cause  of  dysmenorrhoea  and  sterility — pathological  anteflexion 
of  the  uterus  (v.  Anteflexion  of  the  Uterus).  It  is  evident  that  in  this 
way,  too,  we  get  the  uterus  anteflexed  and  drawn  to  one  side,  or  ante- 
flexed  and  drawn  back  (fig.  38). 

Sometimes  pelvic  abscesses  are  found  in  localities  to  be  afterwards 
alluded  to.  Often  the  uterus  and  ovaries  are  in  an  atrophic  condition 
owing  to  compression  of  the  vessels  and  nerves  by  the  cellulitic  attack  ; 
this  quite  agrees  with  the  clinical  fact  that  many  women  with  bad 
pathological  anteflexion  do  not  suffer  much  at  their  periods,  because  the 
withered  condition  of  the  organs  produces  scanty  menstruation.  Accord- 
ing to  some,  we  can  have  no  cellulitis  in  the  broad  ligaments  and  no 
formation  of  pus — abscess  of  the  broad  ligaments.  Clinical,  anatomical, 
and  pathological  evidence  is  in  favour  of  the  occurrence  of  both.  At 
the  same  time,  it  is  almost  impossible  clinically  to  distinguish  abscess 
of  the  broad  ligament  from  an  encysted  serous  pelvic  peritonitis  behind 
it,  pushing  it  forwards. 

ETIOLOGY. 

Etiology.  In  parous  women  the  great  cause  of  pelvic  cellulitis  is  probably  septic 
matter  (i.e.  either  micrococci  or  bacilli,  or  their  products)  absorbed  by 
the  lymphatics  from  the  torn  perineum,  vagina,  or  cervix.  This  passes 
along  the  abundant  lymphatics  and  blood-vessels  in  the  cellular  tissue 
beneath  and  in  the  broad  ligaments,  causing  inflammation  of  the  glands 
and  proliferation  of  the  connective  tissue  in  which  these  are  embedded. 
Thus  we  find  childbirth,  premature  labour,  and  abortion,  often  followed  by 
cellulitic  attacks  for  obvious  reasons.  In  parturition  we  have  the  cervix, 
for  instance,  torn  vertically  at  one  side  ;  and  septic  matter  deposited 
there  often  speedily  spreads  along  the  lymphatic  stream  (v.  Chap.  XVI.). 


PELVIC  CELLULITIS.  169 

In  milliparce,  cellulitis  may  arise  from  the  same  causes  as  are  given 
under  pelvic  peritonitis,  e.g.,  exposure  to  cold  during  menstruation. 

Pelvic  peritonitis,  in  a  minor  degree,  is  always  associated  with  cellu- 
litis as  already  mentioned.  So  far  as  we  have  considered  the  etiology 
of  pelvic  inflammatory  affections,  we  have  associated  them  with  some 
virus,  most  frequently  septic.  We  do  not  believe  that  mere  traumatic 
injury,  apart  from  septicity  and  tension,  can  cause  an  inflammatory 
attack. 

SYMPTOMS. 

The  patient  has  a  rigor  or  chill.     Pain  is  felt  over  the  lower  part  of  Symptoms, 
the  abdomen,  but  it  is  not  so  intense  as  in  peritonitis.     The  pulse  and 
temperature  are  raised.     After  exudation  has  taken  place,  the  patient 
may  have  one  thigh  alone  drawn  up. 

PHYSICAL    SIGNS. 

There  is  pain  on  palpation  of  the  abdomen ;  and  after  exudation  has  Physical 
taken  place,  we  feel  a  fulness  at  one  side  of  the  uterus  or  in  the  iliac Slgns< 
fossa. 

Bimanual  examination,  always  difficult,  reveals  at  first  nothing  but 
increased  heat  and  tenderness.  After  exudation  has  occurred,  it  is  found 
in  the  following  positions  : — 

(1.)  As  a  bulging  at  the  side  of  the  uterus,  depressing  the  lateral 
fornix  and  pushing  the  uterus  usually  to  the  other  side ; 

(2.)   in  the  upper  portion  of  the  broad  ligament,  and  therefore  not 
bulging  downwards ; 

(3.)  in  the  iliac  fossa; 

(4.)  very  rarely,  behind  the  uterus; 

(5.)  almost  never,  between  uterus  and  bladder. 

We  have  seen  pus  pointing  in  the  inguinal  region  on  one  side,  and 
with  no  dipping  down  into  the  pelvis  or  immediate  connection  with 
the  side  of  the  uterus.  When  pus  is  present  in  large  amount,  the 
fluctuation  can  be  felt  bimanually.  When  it  forms  in  the  centre  of  a 
large  inflammatory  exudation,  an  obscure  boggy  feeling  may  or  may  not 
be  made  out.  Aspiration  helps  here  very  much. 

The  course  of  these  exudations,  inflammatory  and  purulent,  is  ex-Explana- 
plained  in  two  ways.  ^^ 

(a.)  By  the  course  of  the  lymphatics,  which  run,  as  we  have  seen,  Exuda- 
from  the  uterus  outwards  beneath  and  between  the  layers  of  the  broad 
ligament  to  the  glands  in  the  lumbar  region. 

(6.)  By  the  lines  of  cleavage  in  the  cellular  tissue  of  the  pelvis.  The 
student  should  refer  back  to  the  description  of  cellular  tissue  of  the 
pelvis  given  in  Chap.  II.,  and  especially  to  Konig's  researches  (page  42). 
Based  on  these,  and  on  clinical  work,  Konig  holds  that — 

(1.)  An  exudation  in  the  broad  ligament,  near  the  tube  and  ovary, 


170 


PERITONEUM  AND  CONNECTIVE  TISSUE. 


passes  first  along  the  psoas  and  iliacus  and  then  sinks  into  the 
true  pelvis ; 

(2.)  exudations  which  begin  primarily  in  the  deeper  cellular  tissue 
on  the  antero-lateral  aspect  of  the  cervix,  pass  first  011  to  the 
cellular  tissue  of  the  true  pelvis  at  the  side  of  the  uterus  and 
bladder,  then  with  the  round  ligament  to  Poupart's  ligament 
beneath  the  inguinal  canal,  and  then  they  pass  outwards  and 
backwards  into  the  iliac  fossa  ; 

(3.)  abscesses,  developing  from  the  posterior  aspect  of  the  broad  liga- 
ments, fill  first  the  postero-lateral  part  of  the  pelvis  and  then 
pass  as  in  (L). 


Differences 
and 
Differ- 
ential 
Diagnosis. 


DIFFERENCES  AND  DIFFERENTIAL  DIAGNOSIS  BETWEEN  ACUTE  PELVIC 
PERITONITIS  AND  CELLULITIS. 


Differences. 

Pelvic  Peritonitis. 


of 


(1.)  Inflammatory    affection 
pelvic  peritoneum  chiefly. 

(2.)  Usually  general,  round  the 
uterus. 


Pelvic  Cellulitis. 

(1.)  Inflammatory    affection     of 
pelvic  cellular  tissue  chiefly. 
(2.)  Usually  lateral. 


Differential  Diagnosis. 

Pelvic  Peritonitis. 

(1.)  Pain  very  severe. 

(2.)  Patient's  legs  drawn  up  on 
both  sides. 

(3.)  Firm  flat  effusion  not  bulg- 
ing intofornices,  and  situated  round 
the  uterus ;  or  a  mesial  bulging  of 
serous  effusion  behind  uterus.  Cer- 
vix (vaginal  portion)  is  of  normal 
length. 

(4.)  Does  not  spread  along  round 
ligament  or  into  iliac  fossa,  but 
may  affect  all  peritoneum. 

(5.)  Uterus  displaced  to  front, 
or  unaltered  in  position. 

(6.)  Vomiting  more  frequent. 


Pelvic  Cellulitis. 

(1.)  Pain  not  so  severe. 

(2.)  Usually  only  one  leg  drawn 
up. 

(3.)  Firm  effusion,  bulging  usu- 
ally into  fornix  of  one  side.  Thus 
cervix  (vaginal  portion)  apparently 
shortened  on  one  side. 


(4.)  Exudation  or  pus  spreads 
in  definite  directions,  and  is  usually 
localised. 

(5.)  Uterus  usually  displaced  to 
one  side. 

(6.)  Vomiting  less  frequent. 


It  is  often  very  difficult  to  differentiate  these  ;  and  therefore  in  some 
cases  the  diagnosis  must  be  pelvic  inflammation — probably  cellulitic  or 
probably  peritonitic,  as  the  case  may  be. 


PELVIC  CELLULITIS.  171 


COURSE  AND  RESULTS. 

Very  often  the  attack  passes  off  and  leaves  no  trace.  The  septic  Course  and 
poison  is  too  small  in  amount  to  do  harm ;  or  it  sets  up  some  inflamma-  ts* 
tory  exudation,  which  mechanically  arrests  progress,  and  then  becomes 
absorbed.  The  vitality  or  health  of  the  tissues  and  the  strength  of  the 
poison  have  also  their  share  in  determining  its  progress.  Exudation  may 
take  place  and  may  be  absorbed  almost  completely,  may  suppurate  slowly, 
and  only  to  a  limited  extent,  and  may  form  a  large  abscess.  This  abscess 
may  open  into  the  bowel  or  bladder,  or  pass  below  Poupart's  ligament, 
or  upwards  beneath  the  kidney.  Karely  does  it  appear  in  the  perineum, 
or  pass  through  the  sciatic  notch  to  the  buttock.  In  one  case  where  the 
last  occurred,  the  patient  complained  of  a  very  deep-seated  pain  just  over 
the  notch. 

It  is  valuable  to  note  how  rarely  the  abscess  perforates  into  the  peri- 
toneal cavity.  The  peritoneal  surfaces  of  the  abdominal  contents  are  in 
contact ;  and  as  the  inflammatory  attack  spreads,  it  sets  up  a  peritonitis 
which  glues  the  adjacent  surfaces  together.  When  pus  does  enter  the 
peritoneal  cavity,  it  sets  up  a  rapidly  fatal  peritonitis. 

Matthews  Duncan  has  recently  pointed  out  that  albuminuria  is  often 
present  in  pelvic  cellulitis  but  not  in  pelvic  peritonitis ;  it  was  present 
in  6  out  of  16  cases  (37 '5  p.  c.)  of  cellulitis  but  absent  in  32  cases  of 
peritonitis. 

PROGNOSIS. 

This  depends  on  the  extent  of  the  inflammatory  attack,  and  its  effect  Prognosis. 
on  the  patient's  health.  Its  septic  origin  usually  causes  anxiety ;  but 
it  does  not  spread  so  rapidly  as  peritonitis.  Resolution  of  inflammatory 
deposits  is  slow.  Pathological  anteflexion  gives  rise  to  troublesome 
dysmenorrhoea  and  sterility.  Prognosis  should  always  be  guarded  as  to 
complete  recovery. 

TREATMENT. 

The  general  and  the  local  treatment  are  exactly  the  same  as  in  pelvic  Treatment, 
peritonitis.  The  occurring  of  suppuration  is  indicated  by  rigors,  and 
should  be  hastened  by  the  hot  douche  and  poultices.  We  may  have 
only  part  or  parts  of  the  exudation  suppurating,  so  that  in  a  cellulitic 
swelling  we  may  have  inflammatory  exudation  containing  separate  abscess 
cavities.  In  these,  tapping  with  Matthieu's  aspirator  is  very  good,  and 
may  be  often  repeated.  Care  should  be  taken  that  the  aspiratory  needle 
has  been  purified  in  carbolic  lotion  (1-20),  and  prior  to  introduction 
dipped  in  carbolic  oil  (1-20). 

When  pus  is  present  in  large  quantity,  the  treatment  varies  according  Treatment 
,1  ,  .  ,    .         .  of  Pelvic 

to  the  part  at  which  it  points.  Abscess. 


172  PERITONEUM  AND  CONNECTIVE  TISSUE. 

(1.)  If  it  point  above  or  below  Poupart's  ligament,  in  the  buttock,  or 
behind  the  kidney,  it  is  to  be  opened  under  Listerism,  and  a  drainage 
tube  inserted.  Results  by  this  method  are  admirable. 

(2.)  If  it  bulge  in  the  vaginal  roof,  it  should  be  opened  as  follows  : — 
pass  Sims'  speculum,  and  open  into  the  cavity  with  Paquelin's  cautery 
at  a  dull  heat ;  make  the  opening  big  enough  to  admit  two  good-sized 
drainage  tubes.  Daily  irrigate  the  cavity  with  weak  carbolic  lotion 
(1-100)  or  boracic  lotion  (1-30).  If  the  discharge  is  profuse  it  may  be 
received  into  pads  of  sublimated  wood-wool  wadding  placed  over  the 
vulva ;  oakum  or  marine  lint  may  be  used  among  the  poor. 

The  drainage  tubes  should  be  double,  and  with  a  small  piece  at  the 
end  at  right  angles  which  prevents  their  slipping  out.  They  should 
not  be  perforated,  as  this  prevents  the  washing  out.  Straight  tubes  can 
be  fastened  with  a  stitch  to  the  edge  of  the  incision. 

The  practitioner  will  very  often  find  the  remains  of  cellulitis  as  an 
indistinct  thickening  in  the  fornices.  For  these,  blisters  in  the  iliac 
regions,  the  glycerine  plug,  and  hot  douche,  are  useful  (v.  under  Chronic 
Ovaritis). 

EFFECTS  OF  PELVIC  PERITONITIS  AND  CELLULITIS  ON  THE  UTERUS. 

Effects  of        It  is  unfortunate  that  uterine  displacements  have  of  late  years  bulked 

Peritonitis 
and  Cellu- 
litis on  the 
Uterus. 


FIG.  115. 
PERITONITIC  ADHESIONS  DRAWING  THE  UTERUS  TO  ONE  SIDE  (Heitzmann). 

so  largely  in  gynecology— we  mean  by  this  that  many  regard  a  uterine 
displacement  in  itself  as  a  condition  sufficient  to  account  for  symptoms 
of  bearing  down  pain,  leucorrhoea,  or  even  for  sterility  and  dysmenorrhoea. 
It  is  a  well-ascertained  fact  that  uterine  displacements  are  in  many  cases 


EFFECTS  OF  PERITONITIS  AND  CELLULITIS.       173 

the  result  of  antecedent  peritonitis  or  cellulitis,  are  mere  physical  signs 
of  these  affections,  and  therefore  secondary  lesions  of  far  less  importance 
than  the  pelvic  inflammation  which  was  the  primary  one. 

These  displacements  might  be  grouped  under  the  two  heads  : — 

A.  those  caused  by  Pelvic  Peritonitis ; 

B.  those  caused  by  Pelvic  Cellulitis. 

A.  Displacements  caused  by  Pelvic  Peritonitis. 

From  the  lymph  effused  and  the  resultant  bands  formed  in  pelvic  Displace- 
peritonitis  the  uterus  becomes  bound  to  the  adjacent  peritoneum  on  thefro^£ 
rectum  (retro version  and  retroposition) ;  or  more  rarely,  to  that  on  the  Peritonitis, 
bladder  (anteversion) ;  sometimes  it  is  twisted  on  its  long  axis  or  matted 
to  the  coil  of  intestine  surrounding  it.     Figs.  113,  114,  115,  illustrate 
these  conditions. 

The  Diagnosis  of  such  adhesions  is  made  by  digital  pressure  through 
the  rectum  in  the  case  of  retroversion,  and  through  the  anterior  fornix 
in  anteversion.  In  the  former  case,  the  immobility  of  the  uterus  is  felt ; 
and  when  pushed  up  so  as  to  be  manipulated  by  the  abdominal  hand, 
replacement  is  found  to  be  impossible ;  or  if  partially  successful,  the  dis- 
placement returns  almost  immediately.  Sometimes  the  retroverted  uterus 
when  not  enlarged  is  replaced  with  difficulty  owing  to  the  cohesion 
of  the  peritoneum  on  the  posterior  uterine  surface  with  the  peritoneum 
behind  it,  and  this  point  has  to  be  borne  in  mind.  The  sound  should 
certainly  not  be  employed  in  cases  with  adhesions ;  as,  by  its  leverage, 
vascular  adhesions  may  be  torn  and  the  haemorrhage  produce  haema- 
tocele  with  subsequent  pelvic  peritonitis. 

B.  Displacements  caused  by  Pelvic  Cellulitis. 

These  are  two  in  number :  viz.  (a.)  Lateriversion  ;  and  (b.)  Pathologi- 
cal Anteflexion  due  to  Utero-sacral  Cellulitis. 

(a.)  Lateriversion  is   the    result  of  cellulitis  in  one  broad  ligament,  Lateri- 
subsequeiit  absorption  of  the  inflammatory  effusion,  and  cicatrisation  ofve 
the  ligament.     The  Diagnosis  of  this  condition  is  easy.     There  is  often 
a  split  of  the  cervix  at  the  side  corresponding  to  the  displacement  as 
well  as  scarring  in  the  fornix  with  coincident  displacement  of  the  cervix. 
Bimanually,  the  uterus  is  felt  drawn  to  the  one  side,  fixed,  and  some- 
times the  body  is  lateriflexed  as  it  were  on  the  cervix.     Bimanual  dis- 
placement of  the  uterus  to  the  non-affected  side  causes  pain.     The  path- 
ology of  this  displacement  in  many  cases  is  that  cellulitis,  probably  septic, 
has  spread  after  parturition  from  the  split  cervix  along  the  lymphatics 
at  the  base  of  and  in  the  broad  ligament ;  effusion  of  lymph,  perhaps  of 
pus,  has  followed  ;   finally  there  result  the  incomplete  resolution  and  pati10. 
cicatrisation  already  mentioned.  logical 

(b.)  Pathological  Anteflexion  due   to   Utero-sacral  Cellulitis  is  one   offlexion. 


174 


PERITONEUM  AND  CONNECTIVE  TISSUE. 


Para- 
metritis 
Chronica 
Atrophi- 
cans. 


the  most  important,  most  intractable,  and  most  misunderstood  of 
lesions.  Its  nature  may  be  thus  described.  A  cellulitis,  in  or  in  the 
neighbourhood  of  the  utero-sacral  ligaments,  has  gone  on  to  cicatrisa- 
tion, — producing  fixation  of  the  uterus  and,  along  with  the  action  of 
intra-abdominal  pressure,  anteflexion  (v.  Chap.  XXXIII.  Displacements 
of  the  Uterus).  This  cellulitis  is  often  the  result  of  abortion,  more 
rarely  of  full-time  parturition ;  it  is  frequently  found  in  nulliparte,  and 
may  in  some  cases  be  due  to  the  zymotic  diseases  of  childhood. 

This  condition  is  diagnosed  as  follows :  on  vaginal  examination,  the 
cervix  is  found  high  up,  because  drawn  back,  and  pointing  usually  down- 
wards and  forwards ;  through  the  anterior  foruix  the  body  of  the  uterus 
is  felt.  Bimanually,  the  uterus  is  recognised  as  lying  anteflexed  as  shown 
in  fig.  38.  Through  the  posterior  fornix  we  feel  thickening  and  fixation  of 
the  tissue  in  the  neighbourhood  of  the  utero-sacral  ligaments,  or  we  may 
sometimes  feel  the  thickened  ligaments  themselves  running  in  a  direc- 
tion forwards  and  inwards.  The  rectal  examination  gives  valuable  in- 
formation, as  the  thickening  is  more  distinctly  felt,  the  anteflexion  is 
more  accurately  mapped  out  and  ovaritis  or  other  inflammatory  thicken- 
ing discovered. 

The  amount  of  fixation  should  be  estimated  by  bimanual  movement 
of  the  uterus,  as  this  helps  in  prognosis.  Often  the  cellulitis  affects 
one  side  of  the  parametric  tissue  and  gives  a  displacement  of  the 
uterus  towards  the  posterior  extremity  of  an  oblique  diameter  of  the 
pelvis. 

We  shall  have  again  to  consider  the  symptoms  and  treatment  of  these 
conditions  in  the  chapter  on  Displacements  of  the  Uterus.  From  what 
has  been  said,  however,  it  will  be  evident  that  their  treatment  should 
be  simply  that  of  chronic  peritonitis  and  cellulitis. 

PARAMETRITIS  CHRONICA  ATROPHICANS. 

We  have  already  described  some  of  the  results  of  acute  pelvic  peri- 
tonitis and  cellulitis  in  causing  pathological  retroversions  and  ante- 
flexions.  W.  A.  Freund  of  Strassburg  has  drawn  attention  to  a  condition 
of  the  pelvic  connective  tissue  similar  in  some  of  its  results  but 
differing  from  what  we  have  described  in  not  having  an  acute  stage. 
He  terms  it  Parametritis  Chronica  Atrophicans  Circumscripta  et  Di/usa. 
His  researches  are  very  valuable  and  explain  results  usually  ascribed  to 
mere  displacements  of  the  uterus  or  the  pathological  condition  of  the 
cervix;  they  also  give  a  basis  for  treatment  or  at  least  show  the  futility 
of  much  of  the  mechanical  treatment  by  pessaries. 

a.  Parametritis  Chronica  Atrophicans  Circumscripta. 
Nature. — A    circumscribed    chronic    inflammatory   process    affecting 
chiefly  the  fascial  and  aponeurotic  thickenings  of  the  fatless  connective 


PARAMETRITIS  CHRONIC  A  ATROPHICANS.         175 

tissue,  and  causing  changes  analogous  to  those  in  cirrhosis  of  the  liver, 
kidney,  and  spleen. 

Etiology. — The  primary  cause  may  lie  in  bladder,  rectum,  or  uterus. 
When  in  the  bladder,  there  has  been  some  ulcerative  process  from  which 
irritation  has  passed  causing  paracystitis  chronica  atrophicans  (inflam- 
mation of  the  connective  tissue  near  the  bladder).  From  the  side  of  the 
bladder,  thickenings  in  the  connective  tissue  pass  outward  and  forward 
and  by  their  ultimate  atrophy  bring  about  viterine  displacement  in  the 
opposite  direction  :  thus,  left  paracystitis  will  cause  retro-dextro-flexion  of 
the  uterus,  while  right  paracystitis  will  bring  about  retro-sinistro-flexion. 

In  the  rectum,  the  starting-point  may  be  dysenteric  or  simple  folli- 
cular  ulceration  at  the  level  usually  of  the  anterior  fold  of  mucous 
membrane  forming  part  of  the  sphincter  tertius.  The  cellulitic  irrita- 
tion runs  in  the  utero-sacral  ligaments  and  causes  pathological  ante- 
flexion.  This  effect  of  rectal  disease  has  not  been  sufficiently  recognised 
in  this  country  and  is  worthy  of  clinical  and  pathological  investigation. 

Freund  records  two  interesting  post-mortems  of  chlorotic  women,  19  and  23  years  of 
age  respectively  :  the  heart,  large  arteries,  and  kidneys  were  hypoplastic  (i.e.  insuffi- 
ciently developed) ;  the  ovaries  were  small  and  cystic ;  chronic  pelvic  peritonitis  was 
present  in  Douglas'  pouch  ;  and  finally,  there  was  follicular  ulceration  above  the  sphincter 
tertius,  and  chronic  paraproctitis  (chronic  inflammation  of  the  connective  tissue  near  the 
rectum)  with  shortening  of  utero-sacral  ligaments. 

In  the  uterus,  split  cervix  is  one  great  cause ;  we  have,  radiating  from 
the  split,  chronic  thickening  running  along  the  base  of  the  broad 
ligament  behind  the  cervix  and  down  to  the  fornix.  By  the  atrophy 
and  cicatrisation  of  these  chronic  inflammatory  thickenings  there  result 
ultimately  displacements  of  the  uterus,  compression  of  the  veins,  and 
therefore  catarrh  of  the  cervix  with  reflex  pains  due  to  alterations  in  the 
sympathetic  filaments  distributed  in  the  connective  tissue, 

In  diagnosis,  careful  examination  (vaginal,  rectal,  and  bimanual) 
reveals  the  thickening  due  to  the  chronic  parametritis,  and  the  conse- 
quent displacement ;  the  initial  lesion  in  bladder,  rectum,  or  uterus, 
may  be  made  out. 

b.  Parametritis  Chronica  Atrophicans  Diffusa. 

We  have  here  a  condition  whose  pathology  is  not  so  evident  as  that  of 
the  circumscribed  form.  It  is  said  to  begin  in  the  base  of  the  broad 
ligaments  and  to  pass  out  to  the  pelvic  walls.  Ultimately,  the  whole 
pelvic  tissue  becomes  dense,  the  veins  partly  narrowed  and  partly 
dilated,  the  arteries  contracted  and  the  ureters  distorted.  Hypersemia 
of  the  urethra,  the  neck  of  the  bladder,  and  rectum,  is  present,  causing 
catarrh ;  while  the  uterus,  at  first  enlarged  and  catarrhal,  finally 
atrophies ;  the  Fallopian  tubes  and  ovaries  also  become  atrophied ;  the 
vagina  is  shortened  and  the  external  genitals  withered. 


176  PERITONEUM  AND  CONNECTIVE  TISSUE. 

On  microscopic  examination,  perineuritis  of  the  sympathetic  plexuses 
in  the  connective  tissue  has  been  found  (H.  W.  Freund).  The  etiology 
is  obscure.  It  may  be  due  to  sexual  excess  or  frequent  child-bearing 
and  excessive  suckling  in  women  with  hypoplasia  of  the  genital  organs 
and  blood  vessels. 

Diagnosis  is  based  on  careful  bimanual  examination  and  determina- 
tion of  the  changes  above  described,  by  attention  to  the  history  and 
carefully  noting  the  conditions  of  menstruation  (at  first  profuse  and 
painful,  and  then  scanty),  as  well  as  the  catarrhal  processes  going  on  in 
the  bladder,  cervix  uteri,  and  rectum. 

Reflex  dia-      Reflex   disturbances  arise  from   both  varieties    of  Parametritis  Atro- 

turbances  .  . 

in  Parame-  phicans,  due  to  the  changes  (from  inflammation  and  pressure)  in  the 

8ymPatnetic  filaments.  We  may  speak  of  these  as  Sympathetic,  Spinal, 
and  Cerebral  Hysteria. 

In  the  Sympathetic  form,  we  have  neuralgia  of  the  stomach  and 
intestines,  aching  kidneys,  vesical  pains,  palpitation  of  the  heart,  and 
disturbances  of  the  respiration. 

In  the  Spinal  group,  there  are  painful  spots  over  the  spinous  pro- 
cesses of  the  cervical,  dorsal,  and  lumbar  vertebrae  ;  the  pains  may 
radiate  laterally  and  we  may  get  pains  in  the  extremities.  Hysterical 
paralysis  may  ultimately  develop. 

In  the  Cerebral  group,  there  is  neuralgia  of  the  fifth  nerve,  hemi- 
crania,  and  fixed  boring  pains. 

The  Prognosis  is  fairly  good  in  the  circumscribed  form  but  not  hope- 
ful in  the  diffuse. 

Treatment. — In  the  circumscribed  form,  the  cause  (in  bladder,  rectum, 
or  cervix)  must,  when  possible,  be  treated.  The  vaginal  hot  douche  and 
bimanual  massage  to  set  up  absorption  and  perhaps  stretch  nerve 
filaments  (as  in  Nussbaum's  nerve-stretching  for  sciatica)  have  done  good. 
The  influence  of  stitching  cervical  lacerations  (Emmet's  operation)  may 
be  beneficial. 

The  usefulness  of  treatment  of  the  uterine  displacements  by  pessaries 
is  evident. 

In  the  diffuse  form  and  when  nervous  symptoms  arise,  we  must  rely 
on  nervous  remedies,  chiefly  bromide  of  potassium.  For  the  neuralgia, 
the  constant  current  and  systematic  massage  may  be  tried;  and,  for 
the  paralysis,  the  interrupted  form. 


CHAPTER    XVIII. 


PELVIC    HJEMATOCELE   AND   HJEMATOMA:    NEW 

GROWTHS  IN  THE  PELVIC  PERITONEUM  AND 

CONNECTIVE  TISSUE. 

LITERATURE. 

H.EMATOCELE  AND  H.EMATOMA. — Aitken,  Lauchlan — Case  of  Pelvic  Haematocele  :  Ed. 
Med.  J.,  1862,  p.  104.  Bandl— Die  Krankheiten  der  Tuben,  etc.,  Billroth's  Hand- 
buch  :  Stuttgart,  1879.  Barboui — The  Diagnosis  of  Advanced  Extra-uterine  Gesta- 
tion after  the  Death  of  the  Foetus :  Edin.  Med.  Jour.,  1882.  .Barnes— Diseases  of 
Women :  London,  1878,  p.  590.  Bernutzand  Goupil — Clinical  Memoirs  of  the  Diseases 
of  Women,  Vol.  II.  :  New  Syd.  Soc.,  Meadows'  Tr.,  1866.  Bernutz — Hematocele 
uterine :  Archiv.  de  Tocologie,  1884,  p.  978.  Bourdon — Tumeurs  fluctuantes  du 
petit  bassin :  Rev.  Med.,  1841.  Crede — Monatsschrift  f.  Geburtskunde,  Bd.  IX., 
S.  1.  Duncan,  Matthews — Uterine  Haematocele:  Ed.  Med.  J.,  1862,  p.  418: 
Diseases  of  Women,  Churchill,  Lond.,  1883.  Diivelius — Beitrag  zur  Lehre  von  der 
operativen  Behandlung  des  Hsematoma  periuteriuum  extraperitoneale  :  Archiv  fur 
Gynak.,  Bd.  XXIII.,  S.  107.  Freund— Die  Gynakologische  Klinik :  Strassburg, 
1885.  Fritsch — Die  retrouterine  Haematocele  :  Volkmann's  Sammlung,  No.  56. 
Gusserow — Ueber  Haematocele  periuterina  :  Arch,  fur  Gyuak.,  Bd.  XXIX.,  Hft.  3. 

Hart  and   Cartel The   Frozen   Sectional  Anatomy  of  advanced   Extra-uterine 

Gestation :  Ed.  Med.  Jour.,  Oct.  1887.  Hunter,  Wm. — Intraperitoneal  Blood 
Transfusion  and  the  Fate  of  Absorbed  Blood  :  Journal  of  Anat.  and  Phys.,  1887. 
Imlach — Pelvic  Haematocele  treated  by  Abdominal  Section  :  Brit.  Med.  Jour.,  1885, 
I.,  983;  and  1886,  I.,  339.  Kuhn— Ueber  Blutergiisse  in  die  breiten  Mutterbander 
und  in  das  den  Uterus  umgebenden  Gewebe :  Zurich,  1874.  M'Clintock — Diseases  of 
Women  :  1853.  Macdonald,  Angus — Uterine  Haematocele,  Ed.  Med.  J.,  Jan.  1883. 
Martin  —  Das  extraperitoneale  periuterine  Hamatom :  Stuttgart,  Enke,  1881. 
Nelaton — Gaz.  des  Hopitaux,  1851  and  1852.  Olshausen — Ueber  Haematocele  und 
Hsematometra :  Arch,  fur  Gynak.,  Bd.  I.,  S.  24.  Pelletan — Clinique  Chirurgicale  : 
Paris,  1810.  Priestley,  W.  O. — Pelvic  Haematocele  :  Reynolds'  System  of  Med., 
Vol.  V.,  p.  783.  Schroeder— Handbuch  der  Krankheiten,  etc.  :  Leipzig,  1878,  S.  453. 
Ueber  die  Bildung  der  Haematocele  retrouterina  und  anteuterina :  Arch.  f. 
Gyn.,  Bd.  V.,  S.  348.  Simpson,  Sir  J.  Y. — Periuterine  or  Pelvic  Haematocele, 
Collected  Works,  Vol.  III.,  p.  121 :  A.  &  C.  Black,  Edinburgh.  Tait,  Lawson— 
Lectures  on  Ectopic  Pregnancy  and  Pelvic  Haematocele  :  Birmingham,  1888.  Tilt — 
Pathology  and  Treatment  of  Sanguineous  Tumours,  Lond.  1853.  Voisin — De  1'hema- 
tocele  Retro-uterine :  These,  Paris,  1858.  Traite  de  1'hematocele :  Paris,  1860. 
Zweifel — Zur  Behandlung  der  Blutergiisse  hinter  der  Gebarmutter  :  Archiv  f.  Gyn., 
Bd.  XXII.,  S.  185.  Zur  Behandlung  der  Blutergiisse  hinter  der  Gebarmutter  : 
Arch.  f.  Gyniik.,  Bd.  XXIII.,  S.  414.  See  also  Index  of  Recent  Gynecological 
Literature  in  the  Appendix. 

PELVIC   HEMATOCELE   AND    HEMATOMA. 

Preliminary   Considerations. — The    abundant    venous   supply  of  theprelimi- 
pelvic  organs,  the  congestion  induced  by  menstruation,  the  haemorrhage naries- 
M 


178         PERITONEUM  AND   CONNECTIVE  TISSUE. 

accompanying  the  monthly  rupture  of  the  Graafian  follicle,  and  espe- 
cially the  rupture  of  an  early  extra-uterine  gestation,  render  women 
peculiarly  liable  to  haemorrhages  into  the  pelvic  cavity.  Yet  it  is 
astonishing  that  it  is  only  since  1850  that  this  subject  has  really 
attracted  gynecologists'  attention.  It  was  in  that  year  that  Nelaton 
gave  the  subject  due  prominence;  although  Eecamier  (1831),  Bourdon, 
Velpeau,  and  Bernutz  had  all  recorded  cases — under  such  titles  as 
"  Bloodgush  from  an  aneurism  of  the  ovary,"  "  Blood  cysts  of  the  pelvic 
cavity."  Nelaton  had  diagnosed  his  case  as  an  abscess,  and  opened  it 
with  a  bistoury ;  the  blood  and  blood  clots  escaping  from  the  incision 
showed  its  real  nature  unmistakably.  Since  that  time  pelvic  hsematocele 
has  taken  its  place  in  Gynecology  as  a  serious  and  important  symptom. 

Terminology. — The  htemorrhage  is  either  intra-peritoneal  or  extra- 
peritoneal,  but  both  forms  may  be  present.  The  terminology  is  at 
present  unsettled.  "  Hsematocele  "  means  "  haemorrhage  into  the  peri- 
toneal cavity"  but  we  may  use  the  phrase  "pelvic  haematocele"  as 
including  both  varieties,  and  add  "intra-peritoneal"  or  "extra- 
peritoneal  "  where  the  diagnosis  can  be  made.  "  Hsematoma "  is 
sometimes  used  instead  of  "extra-peritoneal  heematocele."  "Retro- 
uterine  "  hsematocele  is  employed  when  the  bulging  is  distinctly  behind 
the  uterus. 

NATURE. — An  effusion  of  blood  into  the  pelvic  peritoneum  or  connective 
tissue. 

Pelvic  haematocele  is  thus  not  a  disease.  It  is  only  a  symptom  of 
some  previously  existing  pathological  condition  of  the  pelvic  organs, 
just  as  haemoptysis  is  not  a  disease  but  usually  a  symptom  of  some 
lung  condition. 

PATHOLOGICAL   ANATOMY. 

Patho-  Our  knowledge  on  this  point  is  extremely  defective,  although  of  late 

some  light  has  been  thrown  on  it  by  information  gained  from  abdominal 
section,  and  more  especially  by  the  recent  admirable  work  of  William 
Hunter.  From  experiments  on  the  lower  animals  by  intra-peritoneal 
transfusion  of  blood,  he  has  arrived  at  the  following  conclusions  : — 

"The  results  of  the  foregoing  experiments  may  be  regarded  as  definitely  proving,  that 
in  the  case  of  the  peritoneal  cavity  at  least  the  fate  of  extravasated  blood  is  not  so 
entirely  a  merely  local  one  as  has  hitherto  been  generally  supposed.  On  the  contrary, 
a  very  considerable,  sometimes  even  a  large,  proportion  of  the  red  corpuscles  may  escape 
a  local  fate  altogether,  becoming  absorbed  mainly  through  the  lymphatics  of  the 
diaphragm  into  the  circulation,  where  they  continue,  for  a  certain  time  at  least,  to 
perform  their  functions  as  before. 

"The  rapidity  with  which  this  absorption  takes  place  is  always  both  relatively  and 
absolutely  greatest  during  the  earlier  hours  after  the  effusion,  especially  in  the  case  of 
entire  blood,  the  absorption  extending,  however,  over  a  period  of  twenty -four  hours  or 
even  longer  according  to  the  amount  of  the  effusion. 

"The  maximum  increase  is  attained  to  on  the  third  or  fourth  day  after  the  injec- 


PELVIC  H^EMATOCELE  AND   H^EMATOMA.          179 

tion,  the  time  depending  partly  on  the  quantity  of  blood  transfused,  partly  on  its 
fluidity.     .     .     . 

' '  The  actual  absorption  of  corpuscles  which  takes  place  during  the  earlier  hours  after 
the  transfusion  can,  however,  never  be  accurately  determined,  even  by  enumeration  of 
the  corpuscles  in  the  circulating  blood,  still  less  by  estimation  of  the  hsematoglobin.  For 
owing  to  the  serous  effusion  which  almost  always  occurs  into  the  abdomen  as  the  imme- 
diate result  of  the  injection,  the  number  of  corpuscles  in  the  circulating  blood  as  deter- 
mined by  enumeration,  is  always  apparently  much  increased ;  and  it  is  not  till  this 
effused  serum,  along  with  the  injected  serum,  has  become  reabsorbed,  and  the  injected 
serum  has  become  removed  from  the  circulating  blood,  that  the  actual  amount  of  absorp- 
tion of  corpuscles  which  has  taken  place  becomes  apparent. 

"A  slight  inflammatory  reaction  always  occurs  for  a  few  hours  after  the  injection, 
resulting  in  an  effusion  of  serum  containing  leucocytes,  more  or  less  marked  according  to 
the  amount  of  irritation.  This  effusion  is,  however,  of  short  duration,  ceasing  generally 
in  the  course  of  the  first  few  hours,  after  which  the  effused  serum  along  with  that  of  the 
injected  blood  becomes  reabsorbed  back  into  the  circulation. 

' '  The  irritation  produced  by  the  presence  of  clots  is  probably  of  more  consequence, 
as  it  certainly  is  longer  lasting.  The  resulting  inflammation,  however,  is  generally 
localised.  In  no  instance  at  least  in  these  experiments  was  it  such  as  in  any  way  to 
endanger  life. 

"It  is  in  the  neighbourhood  of  the  female  generative  organs,  and  in  connection  with 
pathological  conditions  of  these  organs,  that  such  extravasations  most  frequently  occur. 
A  few  considerations  only  need  be  presented  here. 

"If  the  extravasation  take  place  extraperitoneally,  e.g.,  between  the  layers  of  the 
broad  ligament,  as  is  probably  the  case  in  the  great  majority  of  instances,  it  is  clear  that 
most  of  the  conditions  will  be  present,  especially  as  regards  the  more  or  less  definite 
boundaries  of  the  extravasated  blood,  to  ensure  the  early  coagulation  of  the  blood,  and 
that,  too,  en  masse.  As  any  absorption  of  corpuscles  which  may  then  occur  can  only 
take  place  through  the  ordinary  lymphatic  channels  of  the  pelvis,  through  which  the 
absorption  of  corpuscles  as  such  is  but  slight,  by  far  the  greater  proportion  of  the  cor- 
puscles will  thus  be  doomed  to  a  local  fate. 

"If,  on  the  other  hand,  the  effusion  of  blood  occur  not  only  extraperitoneally,  but  also 
in  part  into  the  peritoneal  cavity  itself,  as  is  probably  not  unfrequently  the  case,  the 
ultimate  fate  of  the  blood  may  be  different.  Its  coagulation  may  then  be  more  or  less 
delayed,  and  its  absorption  greatly  facilitated  by  the  special  action  of  the  diaphragm  in 
promoting  absorption. 

"The  distribution  of  the  blood  in  such  cases  will  naturally  be,  in  the  first  instance  at 
least,  in  the  neighbourhood  of  the  pelvic  organs,  although  the  peristaltic  action  of  the 
intestines  will  tend  to  distribute  it  more  or  less  amidst  the  coils  of  intestine.  However 
clear  may  be  the  part  played  by  the  diaphragm  in  absorption  in  the  case  of  animals,  in 
whom  the  quantity  of  blood  injected,  relative  to  the  size  of  the  abdomen,  is  so  great,  the 
case  is  otherwise  in  the  human  subject,  where  the  quantity  of  blood,  relative  to  the  size 
of  the  abdomen,  may  be  very  small,  and  the  blood  itself  is  generally  situated  at  that  part 
of  the  abdomen  most  distant  from  the  diaphragm.  It  became  of  interest,  therefore, 
to  determine  what  part  the  diaphragm  played  in  the  absorption  of  small  quantities  of 
fluid. 

"In  two  of  my  experiments  on  rabbits,  in  which  death  took  place  within  a  period  of 
24-36  hours  after  the  injection,  the  inflammation  was  observed  to  be  most  intense  over 
the  under  surface  of  the  diaphragm  and  upper  surface  of  the  liver,  these  surfaces  being 
covered  with  a  thickish  layer  of  fibrinous  lymph,  with,  at  parts,  larger  nodules  of  fibrin 
and  leucocytes.  It  seemed  as  if  the  septic  poison  introduced  had  acted  most  virulently 
at  the  seat  of  its  absorption.  It  has  already  been  seen  that  it  was  in  this  neighbourhood 
that  fluid  blood  was  always  found  most  abundant,  if  examination  were  made  shortly  after 
its  injection."  * 

1  Loc.  cit.,  pp.  461-465. 


180         PERITONEUM  AND   CONNECTIVE  TISSUE. 

It  is  of  the  highest  pathological  importance  to  note  that  in  a  very 
large  proportion  of  the  cases  diseased  ovaries  have  been  found  ;  changes 
in  the  Fallopian  tubes  (dilatation  and  filling  with  blood  or  pus)  being 

less  common. 

The  effused  blood  undergoes  changes  in  course  of  time ;  so  that  blood 
crystals,  granular  corpuscles,  and  oil  drops  are  found  as  traces  of  the 


Hcematoina 


Pouch  ofDouylo.s 


~-  -  -1—  Cervical  canal 

- 

_  Vagina 


Rectum 


FIG.  116. 

FELT  AS  A  RETRO-UTERINE  TUMOUF  IN  CASE  OF  EXTRA-UTERINE  GESTATION 
IN  RIQHT  BROAD  LIGAMENT  (Hart  and  Carter). 


previous  blood  effusion.  In  most  cases  of  recovery,  it  becomes  entirely 
absorbed.  As  the  result  of  abdominal  section  for  ruptured  Fallopian- 
tube  gestation,  it  has  been  noted  that  the  effused  blood  becomes 
increased  in  specific  gravity  and  stains  sponges  deeply. 


PELVIC   H^EMATOCELE  AND   H  JEM  ATOM  A. 


181 


In  the  extra-peritoneal  effusions,  the  fate  of  the  extravasated  blood  is 
to  a  great  extent  local.  The  blood-clot  is  formed  into  connective 
tissue,  and  large  areas  of  blood  crystals  are  found. 

The   practical  deduction  from   all   this   is   that  in   intra-peritoneal  Prognosis, 
effusions  the  majority  of  cases  can  be  tided  over  until  the  effused  blood 
is  absorbed.       Ruptured   Fallopian-tube  gestations  require  abdominal 
section  in  most  instances.     In  extra-peritoneal  effusions  the  immediate 


FIG.  117. 

RETKO-UTERINE  H^EMATOCELE.    Pouch  of  Douglas  not  previously  obliterated  (Schroeder'). 

prognosis   is  much   less   grave,   and  ultimate   recovery  usually  takes 
place. 

ETIOLOGY  :     SOURCES    OF    HAEMORRHAGE    AND    VARIETIES. 

The  table  quoted  below  shows  that  pelvic  hsematocele  is  most  common  Etiology. 
in  women  between  the  ages  of  25  and  35 — that  is,  women  in  their 
period  of  full  menstrual  and  sexual  vigour.     Out  of  43  cases,  the  ages, 
according  to  Schroeder,  were  as  follows  : — 


In     3  cases,  or  7'0  p.  c.,  the  ages  were 


14 
13 

9 
3 

1 


32-5 

30-2 

20-9 

7-0 


22-25 
25-30 
30-35 

35-40 

40-43 

53 


It  is  more  common  in  parous  women ;  there  is  considerable  difference 
of  opinion  as  to  its  frequency,  Olshausen  placing  it  as  high  as  4  p.  c. 
of  all  female  diseases,  while  Schroeder  estimates  it  only  at  '7  p.  c. 


182         PERITONEUM  AND   CONNECTIVE  TISSUE. 

The  following  are  the  chief  causes  of  haemorrhage  and  its  anatomical 
sources. — 

1.  Predisposing   causes.        Profuse    menstruation ;    violent    exercise 
during  menstruation,  such  as  dancing;    violent  coitus  during  mens- 
truation ;    varicose   conditions   of  the  subperitoneal  veins ;    purpura ; 
scorbutus ;  haemophilia. 

2.  Anatomical  sources,    (a.)  Pelvic  Peritoneum. — There  may  be  rupture 
of  veins  of  the  pampiniform  plexus,  or  of  the  veins  below  the  uterine 
peritoneum.     In  the  former  case,  we  may  get  the  blood  pouring  directly 
into  the  peritoneal  cavity ;  or  first  passing  between  the  layers  of  the 
broad  ligament,  and  either  remaining  enclosed  there  or  rupturing  into 
the  peritoneal  cavity.     The  haemorrhage,   according  to  Virchow,  may 


FIG.  118. 
COPIOUS  BLOOD-EFFUSION  ANTE-  AND  RETRO-UTERINE. 

arise  from  vessels  developed  in  the  false  membranes  of  pelvic  peritonitis. 
Crede"  of  Leipzig  quotes  a  case  where  he  tapped  a  tumour  and  first 
got  serum,  then  blood-stained  serum,  and  finally  blood.  In  two  days, 
a  fresh  tapping  first  gave  putrid  blood  and  then  fresh  blood  in 
abundance. 

(6.)  Connective  tissue.—  Rupture  of  veins  occurs  here  also. 

(c.)  Uterus.— We  may  have  regurgitation  in  menorrhagia  from  the 
uterus  along  the  dilated  Fallopian  tubes.  Rupture  of  interstitial  extra- 
uterine  pregnancy  is  another  cause  of  hemorrhage. 

(d.)  Fallopian  tube.—  Blood  may  come  from  its  hypersemic  mucous 
membrane  and  pass  into  the  peritoneal  cavity.  Intra  -  peritoneal 


PELVIC   H^EMATOCELE  AND   II ^EM ATOM  A. 


183 


hsematocele  is  often  the  result  of  the  ruptm-e  of  an  early  Fallopian- 
tube  gestation  intra-peritoneally  (fig.  1 1 9).  When  it  develops  between 
the  layers  of  the  broad  ligament,  hsematoma  is  the  result. 

(e.)  Ovary. — Here  it  results  from  rupture  of  congested  vessels,  or  of 
the  Graafian  follicles. 


Wall  of 
gestation-sac 


Bladder 


Vtero-vetical 
fold  of  peritoneum. 

Placenta 


Cervix  uteri 


Hcematocele  in 
pouch,  of  Douglai 


An 


Perineu 


FIG.  119. 

RECENT  H^EMATOOELE  IN  POUCH  OF  DOUGLAS  from  rupture  of  a  gestation-sac  lying  in  it ;  the  uterus, 
the  cavity  of  which  is  not  exit  into,  is  closely  incorporated  with  anterior  wall  of  sac  (Barbour). 

Of  all  these  causes,  rupture  of  veins  below  the  peritoneum, 
and  rupture  of  Fallopian-tube  pregnancies  are  the  most  common. 
The  student  will  now  clearly  see  the  symptomatic  nature  of  haema- 
tocele. 


184         PERITONEUM  AND   CONNECTIVE  TISSUE. 

SYMPTOMS. 

Symptoms.  The  chief  symptoms  are  menorrhagia,  sudden  onset,  sudden  bloodless- 
ness,  pain.  The  pulse  may  become  feeble  from  anaemia,  and  the  tem- 
perature is  not  above  normal.  Menorrhagia  is  not  always  present, 
and  the  bloodlessness  may  not  be  very  well  marked ;  sometimes  patients 
have  a  sudden  faint  feeling.  In  cases  of  copious  effusion  from  rupture 
of  an  extra-uterine  pregnancy,  the  symptoms  are  often  like  those  of 
irritant  poisoning:  viz.,  sudden  onset,  prostration,  vomiting.  The 
marked  anaemia,  however,  points  to  some  internal  haemorrhage ;  inquiry 
should  then  be  made  as  to  menstruation,  and  this  always  followed  by 
bimanual  examination.  In  Fallopian-tube  gestation  the  decidua  may 
be  discharged  from  the  uterus  before  actual  rupture. 

In  retro-uterine  hsematocele,  we  find  frequent  painful  micturition  and 
difficulty  in  evacuation  of  the  bowels.  There  is  sometimes  retention 
of  urine. 

PHYSICAL   SIGNS. 

Physical         These  differ  according  as  the  effusion  is  intra-  or  extra-peritoneal. 

Intra-peritoneal  Hcematocele. — When  blood  is  poured  out  near  the  pouch 
of  Douglas,  we  may  get  the  following  characteristic  state.  On  abdominal 
percussion,  dulness  may  be  present.  On  vaginal  examination,  a  resistant 
bulging  tumour  is  felt,  varying  in  size  from  that  of  a  billiard  ball  to 
that  of  a  child's  head,  and  sometimes  filling  up  a  large  part  of  the  pelvic 
cavity ;  the  os  uteri  is  pressed  close  behind  the  symphysis,  looks  down- 
ward, and  is  often  almost  inaccessible  (figs.  117  and  119).  A  good  plan  to 
get  at  it  is  to  turn  the  index  finger  palmar  surface  to  the  symphysis,  and 
push  it  well  up.  On  bimamial  examination,  thefundus  uteri  is  felt  unusually 
distinct,  beneath  the  abdominal  walls  and  above  the  pubes,  and  generally  to 
one  or  other  side.  This  settles  the  point  that  the  tumour  is  retro- 
uterine  and  not  the  uterus.  The  sound  confirms  the  Bimanual  as  to 
the  position  of  the  uterus,  but  is  not  as  a  rule  necessary. 

Extra-peritoneal  Hcematocele:  Pelvic  Hcematoma. — When  the  blood- 
effusion  is  poured  out  between  the  layers  of  one  of  the  broad  ligaments, 
we  get  displacement  of  the  uterus  to  the  opposite  side,  arched  dulness 
on  abdominal  percussion  to  one  or  other  side  of  the  hypogastric  region 
with  bulging  more  or  less  marked  in  the  lateral  or  posterior  fornices 
(fig.  116).  When  the  effusion  is  peri-uterine,  we  get  the  abdominal 
dulness  more  extensive  and  the  bulging  in  the  fornices  all  round  the 
uterus.  Pelvic  peritonitis  is  often  a  result  of  the  intra-peritoneal  form 
of  blood-effusion. 

All  that  has  been  given  here  is  only  how  to  recognise  intra-pelvic 
haemorrhage,  which  is  merely  a  symptom  or  sign  of  some  lesion.  The 
diagnosis  of  the  lesion  causing  the  haemorrhage  is,  except  in  the  case 
of  extra-uterine  pregnancy,  as  yet  beyond  our  clinical  knowledge. 


PELVIC  H^EMATOCELE  AND   H^EMATOMA.          185 


DIAGNOSIS    AND    DIFFERENTIAL    DIAGNOSIS. 

Pelvic  hpematocele  requires  to  be  diagnosed  from —  Diagnosis 

Pelvic  peritonitis  followed  by  enclosed  serous  effusion  in  pouch  o/Differ- 

?«**>*.  SfiL. 

Pelvic  cellulitis, 

Fibroid  on  posterior  wall  of  uterus. 

Ovarian  cyst  behind  uterus, 

Extra-uterine  pregnancy, 

Retention  of  blood  in  horn  of  a  malformed  uterus, 

Retroversion  of  non-gravid  or  gravid  uterus. 

Of  these  we  consider  at  present  only  pelvic  peritonitis  and  pelvic 
cellulitis.  The  others  will  be  treated  of  each  under  its  respective 
head. 

In  these  two  purely  inflammatory  affections  we  have  the  inflammatory 
symptoms  from  the  first ;  without  a  history  of  sudden  onset,  of  menor- 
rhagia,  or  of  the  symptoms  of  internal  haemorrhage.  Further,  the 
difference  in  etiology  of  hsematocele  and  peritonitis  will  help  us.  The 
history  is  the  most  important  aid  in  diagnosis. 

COURSE   AND    RESULTS. 

In   many  cases  (4  according  to  Voisin)  the  blood  effused  becomes  Course  and 
entirely  absorbed,  in  a  time  varying  from  2  to  10  months. 

The  tumour,  with  partially  clotted  or  purulent  contents,  may  burst 
into  the  rectum,  vagina,  or  peritoneal  cavity ;  in  the  last  case,  fatal 
peritonitis  follows. 

When  the  blood  effusion  is  very  large,  death  may  be  rapid. 

PROGNOSIS. 

As  to  life. — This  is,  as  a  rule,  settled  soon.     The  most  fatal  cases  are  Prognosis, 
extra-uterine  pregnancies,  and  those  in  which  there  are  no  peritonitic 
adhesions  to  limit  the  blood  effusion.     After  peritonitis  is  set  up,  the 
prognosis  is  much  as  in  pelvic  peritonitis. 

TREATMENT. 

(1.)  At  onset  of  hcemorrhage. 

(2.)    When  suppuration  occurs. 

(1.)  At  onset  of  haemorrhage. — The  treatment  here  is  expectant.  The  Treatment, 
patient  is  to  be  put  at  complete  rest,  with  ice-bags  to  the  abdomen. 
Ergotine  should  be  injected  into  the  buttock.  The  ice-bag  is  to  be  kept 
on  for  several  days,  as  this  will  limit  the  subsequent  peritonitis.  If 
the  patient  is  collapsed,  then  stimulants  and  hypodermic  injections  of 
sulphuric  ether  or  whisky  must  be  freely  used ;  a  large  mustard  poultice 


186         PERITONEUM  AND   CONNECTIVE  TISSUE. 

over  the  abdomen  is  often  serviceable,  both  as  a  blood  derivative  and 
in  allaying  vomiting. 

In  most  cases,  the  source  of  the  bleeding  is  unknown ;  the  present 
state  of  knowledge  does  not  enable  us  to  lay  down  any  rule  as  to  the 
opening  of  the  abdominal  cavity  and  the  attempt  to  ascertain  and 
secure  the  bleeding  source.  In  Fallopian-tube  pregnancies  which  have 
burst,  however,  the  abdomen  has  been  opened  and  the  tube  ligatured  on 
either  side  of  the  rupture ;  Lawson  Tait  has  operated  successfully  on 
forty-two  cases  of  rupture  of  Fallopian-tube  gestation,  but  always  at 
some  period  after  the  rupture.  Sinclair,  Herman,  and  Berry  Hart  in 
this  country,  and  Johnstone  in  America,  have  also  operated  success- 
fully. 

Martin  has  performed  laparotomy  in  four  cases  successfully.  He 
opens  the  abdomen,  incises  the  sac,  clears  out  clots,  ties  vessels,  and 
drains.  When  possible,  the  opening  of  the  blood  sac  should  be  stitched 
to  the  abdominal  wound.  Imlach  of  Liverpool  has  also  recorded  cases 
where  he  opened  the  abdomen  and  tied  the  Fallopian  tubes  along  which 
blood  had  regurgitated.  Accordingly,  we  may  now  look  forward  to  an 
extension  of  more  active  interference  by  abdominal  section.  Zweifel 
has  in  several  cases  incised  the  tumour  per  vaginam,  turned  out  the 
clots  and  drained  the  cavity.  In  Haematoma,  when  absorption  is  very 
slow,  Gusserow  has  had  good  results  by  incising  through  the  vagina, 
washing  out,  and  draining.  When  absorption  is  going  on,  the  treatment 
is  the  same  as  in  pelvic  peritonitis. 

(2.)  After  suppuration  has  occurred. — The  tumour  is  to  be  opened 
and  drained,  as  recommended  at  p.  171  For  suppurating  pelvic  cellulitis. 

Recently,  Lawson  Tait  has  recommended  that  some  pelvic  abscesses 
be  opened  by  abdominal  section,  as  we  often  get  very  tedious  cases 
when  they  perforate  into  the  bowel.  The  following  was  the  treatment 
in  one  of  six  cases  in  which  he  performed  it.  "I  determined  to  open 
it  from  above.  ...  I  found  a  large  cavity  containing  about  two  pints 
of  foetid  pus  with  decomposing  blood-clots.  This  I  carefully  cleansed 
out,  and  after  having  united  the  edges  of  the  opening  into  the  cyst 
carefully  to  the  abdominal  wound,  I  fixed  in  one  of  Koeberle's  drainage 
tubes  five  inches  long.  .  .  .  The  patient  went  home  cured  on  the 
thirtieth  day."  Tait's  cases  were  chiefly  suppurating  hsematoceles 
(Tr.  of  Lond.  Roy.  Med.  and  Chir.  Soc.,  vol.  62). 


NEW  GROWTHS.  187 


NEW  GROWTHS  IN  THE  PELVIC  PERITONEUM  AND 
CONNECTIVE  TISSUE  (BROAD  AND  ROUND  LIGAMENTS). 

LITERATURE. 

PERITONEUM  AND  CONNECTIVE  TISSUE  :  BROAD  LIGAMENT.  Cobbold,  W.  A. — Parasites : 
Churchill,  1879.  Freund,  W.  A.—  Das  Bindegewebe  im  weiblichen  Becken  und 
seine  pathologischen  Veramlerungen  mit  besonderer  Beriicksichtigung  der  parame- 
tritis  chronica  atrophicans  und  der  Echinococcuskrankheit :  Gynakologische  Klinik, 
Strassburg,  1885.  Freund  and  Chadunck — Four  cases  of  Echinococcus  in  the  Female 
Pelvis:  Am.  J.  of  Obstet.,  1874.  Hart,  D.  Berry— Sarcoma  of  pelvic  connective 
tissue  in  Atlas  of  Female  Pelvic  Anatomy  :  Edinburgh,  1884.  Neisser — Die  Echino- 
coccuskrankheit :  Berlin,  1877.  Schatz — Die  Echinokokken  der  Genitalien  und  des 
kleinen  Beckens  beim  Weibe  :  Cent.  f.  Gyn.,  44, 1886.  Simmons — Malignant  disease 
of  female  Sexual  Organs  :  Edin.  Med.  Journ.  Dec.  1885.  Cobbold  and  Neisser  give 
the  literature  on  Echinococci  fully  and  references  to  cases  by  Hewitt,  Corrigan, 
Turner,  Wynne,  and  others. 

ROUND  LIGAMENT. — Goodell — Lessons  in  Gynecology  :  Philadelphia,  1880.  Sanger — 
"VVeitere  Beitrage  zur  Lehre  von  den  primaren  desmoiden  Geschwiilsten  der  Gebar- 
mutterbander,  besonders  der  Ligamenta  rotunda  :  Archiv  f.  Gyn.  XXI.  279  and 
XXIV.  1.  Schroedei — Krankheiten  der  weiblichen  Geschlechtsorgane  :  Leipzig,  1878, 
S.  417.  Thomas— Diseases  of  Women  :  Philadelphia,  1880,  p.  136.  Wile—- Hydrocele 
in  the  Female  :  Am.  J.  of  Obst.,  July  1881,  which  see  for  further  literature.  Winckel 
— Lehrbuch  der  Frauenkrankheiten  :  Stuttgart,  1886. 


TUMOURS    OF    THE    BROAD    LIGAMENT. 

Hsematoma  and  inflammatory  conditions  of  the  broad  ligament  have  Tumours 
been  already  considered.     We  need  only  further  mention  that  we  may  Ljgament. 
have  cysts,  fibroids  (rare),  phleboliths,   cancer,  and  tuberculosis ;  the 
last  two  are  only  parts  of  the  general  peritoneal  affection.      Ovarian 
cysts  may  develop  into  the  Broad  Ligament,  and  cysts  may  develop 
in  the  Broad  Ligament  independently  of  the  Parovarium.     Cysts  of  the 
Broad  Ligament  will  be  considered  along  with  Ovarian  Tumours. 


HYDROCELE    OF    THE    BOUND    LIGAMENT. 

Nature  and  Pathological  Anatomy. — This  is  a  rare  malady,  and  may  Hydrocele 
exist  as  encysted  fluid  about  the  round  ligament  (extra-peritoneal),  or£j    ^^ 
in  the  canal  of  Nuck  —  a  process  of  peritoneum  extending  from  the 
internal  inguinal  ring  into  the  labium  majus.     It  may  be  closed  at  the 
internal  ring,  thus  forming  a  cyst ;  or  it  may  communicate  with  the 
peritoneal  cavity. 

The  fluid  is  serous  in  its  nature ;  it  may  be  olive-green  in  colour. 

Physical  Signs. — (a)  Of  encysted  hydrocele  of  the  cord.  An  oval  trans- 
lucent swelling  exists  in  the  ingiiinal  canal.  It  cannot  be  returned 
into  the  abdominal  cavity,  has  usually  existed  for  some  time,  is  not 
tender  on  pressure,  and  gives  rise  to  no  symptoms.  It  must  be 
differentiated  from  an  ovary  in  the  inguinal  canal,  and  from  incar- 
cerated hernia. 


188         PERITONEUM  AND   CONNECTIVE  TISSUE. 

(b.)  Ofhydrocele  in  the  labium  ma  jus.  The  labium  majus  is  distended 
with  a  fluctuating  tumour,  dull  on  percussion  and  of  translucent 
appearance;  usually,  the  contents  cannot  be  returned  into  the  abdo- 
minal cavity.  Aspiration  gives  a  clear  fluid.  It  is  to  be  diagnosed  from 
hernia  in  the  usual  way. 

Treatment. — Aspiration  and  drainage;  or  aspiration  and  injection  of 
a  few  drops  of  tincture  of  iodine.  Goodell  recommends  that  when  the 
labial  form  communicates  with  the  abdominal  cavity,  the  internal  ring 
should  first  be  firmly  compressed  and  the  injected  fluid  then  sucked  out. 

TUMOURS    OF   THE    ROUND    LIGAMENT. 

Tumours  Fibrous,  myomatous,  sarcomatous  tumours,  and  their  combinations, 
ligament,  have  been  described  in  the  round  ligament  by  Sanger.  They  may 
develop  in  any  part  of  its  course  :  intra-peritoneally ;  within  the 
inguinal  canal ;  or  extra-peritoneally — in  the  abdominal  wall,  the  pelvic 
cellular  tissue  or  the  labia  majora.  Such  tumours  are  rare,  those  of  the 
third  group  (extra-peritoneal)  being  the  most  frequent.  They  may  be 
removed  unless  dipping  down  into  the  pelvis. 

ECHINOCOCCI    IN    THE   PELVIC    ORGANS. 

Echino-          Echinococci  or  Hydatids  are  the  sexually  immature  forms  of  the 
Pely'lc"       Tsenia  echinococcus,  a  small  tapeworm  found  in  the  intestines  of  the 
Organs.       dog.     When  present  in  the  human  body,  they  form  elastic  tumours  and 
may  occur  in  the  female  pelvic  organs. 

Freund,  in  25  years,  met  with  19  cases — of  which  7  were  in  the  pelvic  connective 
tissue :  while  Schatz  met  with  6  out  of  7000  gynecological  and  obstetric  cases  (1  in  1166). 
Schatz  has  also  collected  66  cases  of  Echinococcus  disease  in  the  female  pelvic  organs  and 
found  the  frequency  as  follows  : — 14  in  uterus,  14  at  pelvic  brim,  10  in  Douglas'  pouch, 
7  in  ovary,  7  in  broad  ligament,  7  in  pelvic  connective  tissue,  5  between  rectum  and 
vagina,  2  between  bladder  and  vagina. 

They  may  remain  many  years  without  symptoms  or  may  perforate 
into  bowel  or  bladder.  When  large,  they  cause  pressure  symptoms  on 
bladder  and  rectum.  The  physical  signs  are  those  of  a  tense  elastic 
tumour  without  pain ;  at  first,  usually  situated  near  the  rectum ;  and 
ultimately,  when  increased  in  size,  displacing  the  pelvic  organs  as  an 
ovarian  tumour  would  when  developing  between  the  layers  of  the  broad 
ligament,  i.e.  first  forwards  and  then  upwards.  The  diagnosis  is  often 
difficult  and  tapping  may  be  requisite.  When  they  project  sufficiently 
into  the  abdomen,  the  treatment  is  laparotomy  with  shelling  out  of  the 
tumour ;  or  incision  of  the  sac,  with  careful  cleansing  and  stitching  the 
edges  to  the  abdominal  incision  (v.  Abdominal  Section  in  Appendix). 
When  pelvic,  the  sac  is  opened  and  drained  (v.  pp.  171-2).  Hydatids  are 
rare  in  this  country,  but  common  in  Iceland  and  Australia  (Cobbold). 


NEW  GROWTHS. 


189 


TUMOURS    OF    THE    PELVIC    CONNECTIVE    TISSUE. 

We  may  have  fibromyomata,  sarcomata,  or  dermoid  cysts  as  primary  Tumours 
conditions  in  the  pelvic  connective  tissue.  °f  Pelvic 

Fig.  120  shows  the  pelvis  from  an  interesting  case  of  primary  sarcoma  Tissue. 
Avhich  began  in  the  connective  tissue  at  the  left  side  of  the  uterus  and 
spread  through  the  lymphatic  glands.     This  case  presented  the  follow- 
ing points  of  interest. 

A.  B.,  set.  twenty-seven,  was  an  undersized,  wretchedly  thin  girl,  who  had  felt  unable 
for  her  usual  occupation  of  a  domestic  servant ;  but  the  medical  man  whom  she  had  con- 
sulted had  been  unable  at  first  to  find  anything  tangible  to  account  for  her  condition. 
Afterwards,  however,  the  inguinal  glands  of  the  left  groin  (those  parallel  to  Poupart's 
ligament)  began  to  be  enlarged,  and  the  left  leg  was  painful  and  somewhat  swollen.  In 


FIG.  120. 

SARCOMATOUS  TUMOUR  OF  THE  PELVIC  CONNECTIVE  TISSUE  (Hart). 
A  Tumour,  B  Uterus,  Bl  Bladder,  Ov  Ovary,  c  c  Inguinal  and  c'  c'  Sacral  Lymphatic  Glands. 

the  vast  majority  of  cases,  enlargement  of  the  inguinal  glands  parallel  to  Poupart's  liga- 
ment means  some  irritation  in  the  external  genitals  or  lower  fourth  of  the  vagina,  an 
irritation  either  syphilitic,  gonorrhceal,  or  cancerous.  The  external  genitals  and  vagina 
were  in  this  girl,  however,  perfectly  healthy,  and  the  condition  of  the  parts  was,  further, 
virginal.  Deep  palpation  of  the  left  iliac  region  gave  a  sense  of  resistance  at  the  left 
margin  of  the  true  pelvis ;  and,  on  bimanual  examination  of  the  pelvic  organs,  the 
normal-sized  uterus  was  lying  close  to  the  right  margin  of  the  true  pelvis ;  at  the  left 
side  of  the  true  pelvis  could  be  felt  a  firm  resisting  mass,  about  the  size  of  half  a  cocoa- 
nut.  It  seemed  firmly  fixed  to  the  pelvic  wall,  and  gave  no  feeling  of  fluctuation.  Any 
operation  was  hopeless,  and  one  could  only  palliate  the  pain  by  large  doses  of  morphia 
given  hypodermically. 


190         PERITONEUM  AND   CONNECTIVE  TISSUE. 

The  girl  died  miserably  about  six  months  afterwards.  On  post- 
mortem the  pelvis  was  removed,  and  fig.  1 20  gives  a  view  of  the  parts 
as  seen  through  the  brim.  The  displaced  uterus  (B),  subperitoneal 
malignant  mass  (A),  enlarged  inguinal  glands  on  both  sides  (c  c),  and 
the  large  mass  of  the  sacral  glands  (c'  c')  are  well  seen,  On  more  minute 
examination,  the  enlarged  obturator  glands  were  found,  as  well  as  the 
sacral  ones  in  front  of  the  sacrum.  The  primary  tumour  (A)  did  not 
communicate  directly  with  the  enlarged  left  inguinal  glands.  Micro- 
scopical examination  showed  it  to  be  a  round-celled  sarcoma.  This 
case  illustrates  not  only  a  rare  form  of  pelvic  disease  but  also  lymphatic 
communication  between  the  obturator  glands  and  those  of  the  inguinal 
glands  parallel  to  Poupart's  ligament. 

Sarcoma  may  also  arise  in  the  recto-vaginal  septum  and  produce  a 
swelling  simulating,  from  its  position  and  the  displacement  caused  by 
it,  a  retro-uterine  tumour  in  the  pouch  of  Douglas. 


SECTION    IT. 

AFFECTIONS   OF   THE   FALLOPIAN   TUBES   AND 
OVARIES. 

CHAPTER  XIX.  Affections  of  Fallopian  Tube. and  Parovarium. 

„         XX.  Malformations    of  Ovary :    Ovaritis   and   Periovaritis  : 
Displacements  of  Ovary — Hernia,  Prolapsus. 

,,       XXI.  Operations  for  Removal  of  Fallopian  Tubes  and  Ovaries. 

,,  XXII.  Pathology  of  Ovarian  Tumours. 

,,  XXIII.  Diagnosis  of  Ovarian  Tumours. 

,,  XXIV.  Operative  Treatment  of  Ovarian  Tumours. 


CHAPTER   XIX. 

AFFECTIONS  OF  FALLOPIAN  TUBE  AND  PABOVABIUM. 

LITERATURE. 

£andl — Die  Krankheiten  der  Tuben,  etc.,  Billroth's  Handbuch  :  Stuttgart,  1879.  Barnes 
— Diseases  of  Women :  London,  1878,  p.  376.  Doran — Clinical  and  Pathological 
Observations  on  Tumours  of  the  Ovary,  Fallopian  Tube,  and  Broad  Ligament : 
London,  1884.  v.  also  Trans.  Path.  Soc.,  Lond.,1887;  and  Trans,  of  Lond.  Obst. 
Soc.,  1887.  Duncan— Diseases  of  "Women:  Lond.,  1882.  Foidcr,  J.  K.—  Hydro- 
and  Pyo-Salpinx :  Med.  Times  and  Gazette,  1884.  Freund — Ueber  die  Indika- 
tionen  zur  opera  tiven  Behandlung  der  erkrankten  Tuben :  Volk.  Sam  ml.,  ZSo.  323. 
Griffiths — Tubo-ovarian  Cysts:  Trans.  Lond.  Obst.  Soc.,  1887.  Hcnnig — Krank- 
heiten der  Eileiter  und  die  Tubarschwangerschaft :  Stuttgart,  1876.  Klob — Patho- 
logische  Anatomie  der  weiblichen  Sexualorgane :  Wien,  1874.  Lewers — On  the 
Frequency  of  Pathological  Conditions  of  the  Fallopian  Tubes :  Trans,  of  Lond. 
Obst.  Soc.,  1887.  MacDonald,  Angus — Ten  Cases  of  Laparotomy :  Ed.  Med. 
Jouni.,  June  1885.  Martin — Ueber  Tubenerkrankung :  Zts.  fur  Geb.,  Bd.  XIII., 
S.  299.  Noegyerath — The  Vesico-vaginal  and  Vesico-rectal  Touch  :  Am.  J.  of  Obst., 
VIII..  p.  123.  Sdngei — Etiology,  Pathology,  and  Classification  of  Salpingitis  :  Amer. 
Jour,  of  Obst.,  1887,  p.  317.  Simpson,  Sir  J.  Y. — Diseases  of  "\Vomen  (Edit. 
A.  R.  Simpson),  p.  539.  Schrocder — Handbuch  der  Krankheiten,  etc.  :  Leipzig, 
1878,  S.  329.  Tait— Menstrual  Fluid  retained  in  the  Left  Fallopian  Tube  simulating 
Ovarian  Tumour:  Br.  Med.  J.,  1878,  p.  677.  The  Pathology  and  Treatment  of 
Diseases  of  the  Ovaries :  Birmingham,  1883.  Note  on  Chronic  Inflammatory 
Disease  of  the  Uterine  Appendages :  Ed.  Med.  Jour.,  Sept.  1885.  Thomas — 
Diseases  of  Women :  Philadelphia,  1880,  p.  760.  Wells,  Sir  T.  S.  —Diseases  of  Ovarian 
and  Uterine  Tumours  :  London,  1882.  Williams — Ovarian  Tumours  :  Reynold's 
System  of  Medicine,  Vol.  V.  Winckel — Die  Pathologic  der  weiblichen  Sexual- 
organe :  Leipzig,  1881.  Wylie,  W.  G. — Operations  for  Salpingitis  :  N.  Y.  Medical 
Record,  Aug.  29th,  1885.  Zemunn — Ueber  die  Aktinomykose  des  Bauchfells  und 
der  Baucheingeweide  beim  Menschen  :  Medicin.  Jahrbiicher  der  K.  K.  Gesellschaft 
der  Aertzte  in  Wien,  1883,  S.  477.  For  other  literature  see  Bandl  and  Doran,  whose 
works  and  that  of  Hennig  we  mainly  follow  :  see  also  the  Index  of  Recent  Gyne- 
cological Literature  in  the  Appendix. 

FALLOPIAN  TUBE. 

Fallopian  Preliminary  Considerations. — The  anatomical  relations  of  the  Fallo- 
Tube.  pjan  tubes  have  been  already  considered  (p.  22).  Functionally,  they 
act  as  ducts  along  which  the  ovum,  fertilised  or  non-fertilised, 
is  carried  to  the  uterine  cavity;  and  up  which  some  believe  the 
spermatozoids  pass  to  fertilise  the  ovum.  So  far  as  we  know  this 
is  all  their  physiological  function,  unless  we  hold  with  Tait  that  they 
play  some  important  though  as  yet  undefined  part  in  menstruation. 
Pathologically,  the  Fallopian  tubes  are  important  from  the  occurrence 


ABNORMALITIES  OF  TUBES.  193 

of  extra-uterine  pregnancy  in  them  and  their  not  infrequent  dilatation 
with  pus  or  blood.  From  the  fact  that  they  open  on  the  one  hand  into 
the  uterus  and  on  the  other  hand  into  the  peritoneal  cavity,  very  serious 
results  may  follow  from  fluid  accumulations  in  them ;  as  also  from 
spreading  gonorrhoea,  or  from  injections  into  the  uterus.  It  is  of  great 
interest  to  note  the  fact  that  the  majority  of  inflammatory  pelvic 
affections  lie  posterior  to  the  broad  ligaments,  suggesting  their 
etiological  relations  to  Fallopian-tube  disease. 

Can  the  normal  Fallopian  tubes  be  palpated  in  the  Bimanual  ?  The 
student  will  probably  have  already  noted  that,  in  considering  the 
Bimanual  (Chap.  VIII.),  we  did  not  name  the  Fallopian  tubes  as  structures 
whose  form  and  limits  he  was  expected  to  define.  In  a  very  favourable 
case,  the  conjoined  manipulation  may  recognise  them  at  their  uterine 
origin  more  especially  if  the  rectal  examination  be  made  and  the  uterus 
be  well  drawn  down  with  the  volsella.  Nceggerath  has  pointed  out 
that  they  may  be  defined  in  those  cases  where  the  finger  is  passed  along 
the  urethra  to  explore  the  interior  of  the  bladder,  an  operative  procedure 
to  be  described  afterwards.  Practically,  the  Fallopian  tubes  (unless 
much  dilated)  are  not  palpable  on  ordinary  examination.  It  must  not 
be  forgotten  that  many  cases  have  now  been  recorded,  where  abdominal 
section  showed  the  Fallopian  tubes  to  be  dilated  with  pus  to  the  size  of 
coils  of  small  intestine,  although  the  most  careful  Bimanual  had  failed 
to  detect  their  presence. 

Catketerisation  of  the  tubes. — In  certain  undoubted  cases  the  uterine  Catheteri- 
sound  has  been  passed  along  the  Fallopian  tube,  while  in  others  the  ^^  ° 
supposed    sounding    of  the   tube   has  been   really  the  perforation   of 
the  uterine  wall.     It  is  impracticable  to  sound  the  normal  Fallopian 
tubes  to   any   effect;  and   the   procedure   is  by  no  means  devoid  of 
danger. 

We  now  consider  their  pathological  conditions  under  the  following 
heads  : — 

Abnormalities, 

Stricture  and  Occlusion, 

Patent  condition, 

Inflammatory  conditions, 

Hydrosalpinx, 

Pyosalpinx  and  Hsematosalpinx, 

New  Formations,  Tubo-ovarian  Cysts. 

ABNORMALITIES. 

These  are  of  little  practical  interest.     The  chief  are  an  accessory  Abnor- 
fimbriated  end ;  defective  development ;  displacement ;  want  of  apposi- mallties- 
tion  of  fimbrise  to  ovary  (Lawson  Tait). 

N 


194  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 


Stricture 

and 

Occlusion. 


Patency. 


STRICTURE    AND    OCCLUSION    OF    THE    TUBES. 

The  tube  may  have  a  congenital  stricture  ;  or  may  become  closed  at 
the  uterine  or  the  fimbriated  end,  or  in  the  middle.  When  stricture 
occurs  at  the  uterine  end,  it  is  caused  by  implantation  of  the  placenta 
there  or  by  endometritis  with  adhesion.  In  the  middle,  small  tumours 
or  adhesions  may  cause  strictures — in  the  latter  case  usually  partial. 
At  the  fimbriated  end,  the  occlusion  is  due  to  a  catarrh  of  the  tubes 
which  has  spread  to  the  peritoneum  and  set  up  adhesive  peritonitis. 

These  strictures  are  of  importance  in  relation  to  sterility  and  fluid 
accumulations  (pus,  serum,  blood)  which  they  favour ;  but  in  themselves 
cannot  be  diagnosed  during  life. 

PATENT    CONDITION    OF    THE    TUBES. 

By  this  is  meant  undue  dilatability.     It  is  of  great  importance  in 


FIG.  121. 

HYDBOPS  TUBJS  :  a  Uterus  with  Cervix  laid  open  in  front ;   Ib  Fallopian  Tubes ;  cc  hydrops ; 
d  part  of  an  inflammatory  adhesion  ;  ee  ovaries  (Hennig). 

relation  to  uterine  injections.  Even  in  careful  injection  of  the  uterine 
cavity,  post  partum  or  otherwise,  fatal  results  have  followed  from  the 
fluid's  passing  along  the  tube  into  the  peritoneal  cavity.  "Forcible 
uterine  injections  on  the  cadaver,  with  the  cervix  entirely  filled  up  by 
the  syringe,  almost  always  sent  fluid  along  the  tubes  into  the  peritoneal 
cavity.  Less  forcible  injections  under  like  conditions  sent  the  fluid 
along  a  less  distance  (2-3  mm.),  and  often  sent  it  into  the  veins  ;  while 
gentle  injections  with  a  tube  not  filling  the  cervical  canal  sent  fluid 
neither  into  the  tubes  nor  veins."  Bandl,  from  whom  the  above  is 
taken,  records  a  case  where  death  resulted  from  injection  of  an  aborting 
uterus  with  perchloride  of  iron,  although  the  injection  pipe  was  less  in 


SALPINGITIS.  195 

diameter  than  the  cervix.  Death  may  be  immediate  from  shock,  or 
some  days  after  from  peritonitis.  In  uterine  injections,  110  more  than 
1-4  drops  should  be  used. 

Winckel  has  recorded  a  unique  case  where  a  round  worm  (Ascaris 
Lumbricoides)  was  found  calcified  on  the  posterior  surface  of  the  uterus 
and  left  broad  ligament.  It  had  probably  passed  from  the  anus  into  the 
vagina  and  ultimately  through  the  Fallopian  tube  into  the  peritoneal 
cavity. 

INFLAMMATORY    CONDITIONS    OF    THE    TUBES,    SALPINGITIS. 

The  Fallopian  tube  has  three  layers — peritoneal,  muscular,  and  Salpingitis 
mucous.  An  inflammatory  condition  of  the  peritoneum  (perisalpingitis) 
is  simply  part  of  ordinary  pelvic  peritonitis,  is  not  diagnosable,  and  is 
not  in  itself  of  any  importance.  The  same  may  be  said  of  meso- 
salpingitis  (inflammation  of  the  muscular  coat).  The  most  important 
changes  occur  in  the  mucous  membrane. 

Pathology. — The  pathology  of  these  changes  is  not  by  any  means 
thoroughly  worked  out,  and  our  knowledge  is  specially  deficient  in 
regard  to  the  part  played  by  micro-organisms  in  its  production.  We 
here  briefly  take  up  the  varieties  mentioned  below,  following  Sanger's 
classification. 

GROUP  I. — Forms  of  Salpingitis  y^roduced  by  knoivn  specific  microbes. 

1.  Salpingitis  gonorrhoica,  produced  by  the  gonococcus  of  Neisser  ; 

2.  Salpingitis  tuberculosa,  produced  by  the  bacillus  tuberculosis  of 

Koch ; 

3.  Salpingitis  actinomycotica,  produced  by  the  actinomyces  bovis  of 

Bellinger. 

1.  Salpingitis  gonorrhoica. — This  is  held    by  many  to  be  the  most 
frequent  form.     It  should  be  kept  in  mind,  however,  that  the  gonococcus 
is  not  by  any  means  readily  demonstrated  in  the  secretion  of  the  tubes 
in    these    cases,    probably    because    the    organism    is   in    greater   part 
destroyed  by  the  leucocytes.     The  history  is  here  at  present  our  great 
guide  to  the  special  diagnosis. 

2.  Salpingitis  tuberculosa  is  now  thoroughly  proved,  thanks  to  Koch's 
discovery,  by  the  presence  of  the  bacillus  tuberculosis.     To  the  naked 
eye,  the  tubes  appear  somewhat  enlarged  and  beaded. 

3.  Salpingitis   actinomycotica. — This  is   a  pathological  curiosity,  but 
has  been  demonstrated  by  Zemann. 

GROUP  II. — Forms  of  Salpingitis  due  to  specific  microbes  identical 
with,  those  producing  traumatic  infection. 

4.  Salpingitis  septica. — No  special  microbes  have  been  demonstrated 
here,  but  they  are  in  all  probability  identical  with  those  found  to  cause 


196  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

acute  suppuration,  viz.,  streptococcus  pyogenes  and  staphylococcus 
pyogeues.  This  form  follows  abortion,  puerperal  fever,  and  use  of 
tents  or  stem  pessaries. 

GROUP  III.  —  Farms  of  infectious  Salpingitis  produced  by 

specific  but  as  yet  unknown  microbes. 
5.  Salpingitis  syphilitica  is  the  chief  one  of  this  group. 

Another  classification  is  that  of  Martin  into— 

1.  Salpingitis  catarrhalis,  Endosalpingitis  ; 

2.  Salpingitis  interstitialis  ; 

3.  Salpingilis  follicularis. 

In  the  first,  we  have  small-celled  infiltration  causing  thickening  of  the 
mucosa;  in  the  second,  the  same  chiefly  affects  the  muscular  coat; 
while  in  the  third,  the  spaces  in  the  mucous  membrane  of  the  tube 
caused  by  the  folding  of  the  mucous  coat  are  dilated. 

Treatment.  —  This  will  be  considered  under  the  Treatment  of  Pyosalpinx. 


HYDEOSALPINX  OR  HYDROPS 

Hydro-  As    the    result    of    strictiire   of    the    tube    and    marked    catarrh, 

B^P31*-      we    get    the    tube    distended    with    serum    (hydrosalpinx)    or    pus 
(pyosalpinx). 

Pathological  Anatomy.  —  The  whole  or  only  a  part  of  the  tube  is  dil- 
ated, according  to  the  locality  of  the  stricture  (fig.  121).  There  maybe 
several  strictures  and  thus  several  cysts.  The  tube  distends  and 
atrophies,  so  that  the  mucous  membrane  becomes  thin  and  the  muscular 
coat  disappears.  The  fluid  is  usually  serum  with  cholesterin,  and 
occasionally  blood. 

It  is  alleged  that  fluid  can  accumulate  in  the  tube  although  the 
uterine  end  is  open  ;  the  fluid  at  a  certain  stage  of  its  accumulation 
flows  into  the  uterus  (profluent  dropsy  of  the  tube). 

Physical  Signs.  —  An  elongated  tortuous  tube  is  found  at  one 
side  of  the  uterus  and  high  up  in  the  pelvis.  Usually  a  small 
piece  of  the  undilated  tube  can  be  felt  between  the  sac  and  the 
uterus. 

The  Differential  Diagnosis  must  be  made  from  the  following  :  — 

(1.)  Inflammatory  conditions  or  blood  extravasation  in  the  broad 

ligament, 

(2.)  Fallopian-tube  pregnancy, 
(3.)  Small  ovarian  cyst, 
(4.)  Parovarian  cyst, 

(5.)  Retention  of  blood  in  malformed  uterus. 

Treatment.  —  When  the  dilated  tubes  are  free  or  but  partially  adherent, 
they  may  be  removed  by  abdominal  incision  (v.  Pyosalpinx). 


PYOSALPINX.  197 

PYOSALPINX. 

Pyosalpinx  arises  when  the  fimbriated  end  of  the  tube  is  closed  andPyosal- 
the  secretions  thus  retained.     The  usual  explanation  is  that  the  puspmx* 
exuding  from  the  ostium  abdominale  of  the  tube  sets  up  a  limited 
pelvic  peritonitis   and   thus  closes  it.       The   tube   so  distended   may 
rupture  into  the  peritoneal  cavity  with  a  fatal  result. 

Until  recently  it  was  not  believed  that  the  Fallopian  tubes  played  an 
important  part  in  diseases  of  women.  Lawson  Tait's  abdominal  sections, 
however,  reveal  the  fact  that  Pyosalpinx  is  present  in  a  number  of  cases 
hitherto  unsuspected.  Although  this  was  not  believed  at  first,  it  has 
been  amply  proved  not  only  by  abdominal  sections  of  other  gynecologists, 
but  also  by  careful  post  mortem  examination.  J.  K.  Fowler  found  in 
the  post  mortem  record  for  3  years  of  the  Middlesex  hospital,  15  cases 
of  pyosalpinx  ;  in  8  of  these,  it  had  been  the  cause  of  death.  Tait's  state- 
ments have  therefore  been  fully  borne  out. 

When  acute,  the  disease  may  run  its  course  rapidly  from  general  perito- 
nitis. Indeed  in  cases  of  general  peritonitis,  this  lesion  should  be  kept 
in  mind  ;  and  Tait  believes  we  may  save  such  "  by  boldly  opening  the 
abdomen  and  cleansing  its  cavity."  In  chronic  cases,  there  has  prob- 
ably been  some  attack  of  ovaritis  or  peri-ovaritis,  with  occlusion  of  the 
fimbriated  end  of  the  tube,  and  accumulation  of  inflammatory  secretion. 

Symptoms. — -It  is  not  possible  at  present  to  give  any  very  accurate  Symptoms, 
symptomatology  of  this  disease.  The  cases  are  usually  chronic,  have 
been  under  many  gynecologists,  and  not  improved  under  treatment. 
Pain,  intolerable  dysmenorrhoea,  recurrent  attacks  of  pelvic  peritonitis, 
probably  due  to  the  escape  of  pus  from  the  ostium  abdominale  of  the 
tube  into  the  peritoneal  cavity,  and  a  chronicity  of  the  symptoms  should 
lead  one  to  suspect  pyosalpinx.  The  history  often  helps,  as  in  many 
cases  we  find  that  gonorrhoeal  infection  has  started  a  specific  vaginitis 
which  has  spread  until  the  Fallopian  tubes  have  become  seriously 
involved.  Menstruation  is  irregular — usually  increased  both  in  amount 
and  frequency. 

There  have  also  been  described  recurrent  lateral  swellings  in  the 
region  of  the  uterus,  their  disappearance  being  accompanied  sometimes 
with  an  escape  of  pus  from  the  vagina.  These  are  probably  cases  of 
pyosalpinx  discharging  periodically  through  the  uterine  cavity. 

Physical  Signs. — Bimanually  one  finds  swellings  in  the  site  of  the 
tubes,  and  can  make  out  occasionally  that  these  are  sausage-like  in  form. 
Pain  is  felt  on  examination.  Lawson  Tait,  to  whose  work  on  Diseases 
of  the  Ovaries  we  are  indebted  for  the  symptomatology  and  physical 
signs,  narrates  several  cases  of  which  the  two  following  are  examples. — 

"E.  C. ,  aged  thirty-two,  was  married  at  seventeen  years  of  age,  and  had  her  first 

child  when  she  was  eighteen,  and  her  second  in  the  following  year.     She  was  quite  well 
until  1876,  when  she  had  a  smart  attack  of  inflammation  of  the  pelvis,  and  ever  after 


198  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

that  she  had  extreme  pain  at  her  periods,  when  she  had  to  remain  in  bed  for  several 
days ;  and  she  described  her  sufferings  as  amounting  to  agony,  and  resembling  labour-pains 
more  than  anything  she  knew  of.  She  was  seldom  free  from  pain  in  the  back,  and  for 
the  last  three  years  she  has  been  utterly  unable  to  endure  married  life.  I  found  the 
uterus  slightly  retroverted,  and  on  each  side  of  it  there  was  a  distinct  mass  in  the  posi- 
tion of  the  ovary,  large,  fixed,  and  extremely  tender.  She  bad  been  under  a  great 
variety  of  treatments,  without  the  slightest  benefit.  On  October  5th,  1880,  I  made  an 
exploratory  incision,  and  found  both  ovaries  adherent  in  the  cul-de-sac,  the  infundibula 
of  both  tubes  occluded,  and  the  tubes  themselves  distended  into  cysts.  The  whole  of  the 
organs  were  matted  together,  and  the  operation  for  their  complete  removal  was  extremely 
difficult.  The  amount  of  fluid  in  each  tube  was  about  two  ounces.  She  made  an 
uninterrupted  recovery  from  the  operation  until  the  monthly  period  after,  at  which  time 
she  had  a  small  hsematocele  on  the  right  side,  coincident  with  a  slight  menstrual  appear- 
ance. From  this,  however,  she  speedily  recovered,  and  on  February  17th  last  I 
found  the  uterus  perfectly  free  and  normal  in  direction,  I  last  saw  her  on  March  26th, 
and  found  her  in  perfect  health,  absolutely  free  from  pain,  and  she  told  me  that  she  had 
seen  no  appearance  of  menstruation  since  November,  and  that  marital  functions  had 
been  resumed  without  the  slightest  pain. 

"  H.  S. ,  aged  thirty-seven,  had  been  married  seventeen  years,  and  had  only  one  child, 

fifteen  years  ago.  She  did  not  recover  well  from  that  confinement,  and  ever  since  had 
menstruated  too  often  and  too  profusely,  being  rarely  a  fortnight  clear.  I  found  the 
fundus  large  and  tender,  somewhat  anteverted,  and  what  I  regarded  as  the  ovaries 
formed  two  large  masses  low  down,  and  somewhat  behind  the  uterus.  For  a  long  time 
past,  sexual  intercourse  had  been  impossible  on  account  of  the  suffering  it  caused  her. 
Dr  C.  H.  Phillips  of  Hanley,  who  placed  her  iinder  my  care,  had  exercised  a  large 
amount  of  ingenuity  in  her  treatment  without  any  benefit,  and  from  February  till 
August  1880,  we  conducted  further  treatment  equally  in  vain.  On  August  3rd,  I  opened 
the  abdomen,  and  found  the  ovaries  large,  completely  adherent  in  the  cul-de-sac, 
covered  with  lymph,  and  having  the  infundibula  of  the  tubes  occluded.  The  tubes 
were  distended  into  large  cysts,  each  containing  from  four  to  five  ounces  of  clear  serum. 
The  organs  had  to  be  very  carefully  detached,  as  the  adhesions  were  extremely  firm,  and 
the  haemorrhage  during  the  operation  was  tolerably  profuse.  Her  recovery  from  the 
operation  was  rapid  and  easy,  and  the  only  distresses  she  encountered  were  the  climacteric 
flushings.  In  May  last,  Dr  Phillips  sent  me  a  most  satisfactory  account  of  her  condition. " 

Treatment.  Treatment.'1 — The  treatment  hitherto  advised  in  such  cases  has  been 
to  tap.  Lawson  Tait  has  introduced  abdominal  section  with  removal  of 
the  tubes,  and  has  proved  that  this  is  the  safest  and  best  method  of 
treatment.  He  makes  a  small  abdominal  incision,  frees  adhesions  by 
manipulation  with  the  fingers,  and  taps  any  cysts  with  a  long  curved 
trocar  guided  by  the  fingers.  When  adhesions  are  thus  broken  down, 
he  brings  up  the  tubes  to  or  through  the  abdominal  incision,  ligatures 
with  the  Staffordshire  knot,  cuts  away  the  parts  above  the  ligature, 
drops  the  pedicle  and  drains  with  a  glass  tube.  Where  he  cannot  remove 
the  tube,  he  stitches  the  opening  in  it  carefully  to  the  abdominal 
incision.  Some  operators,  especially  in  Germany,  make  a  larger  incision, 
aPply  ligatures  to  adhesions,  and  do  not  hesitate  to  turn  out  the  small 
intestines  (suitably  covered  with  warm  towels)  to  facilitate  this. 

HJEMATOSALPINX. 

Thi8  is  a  rare  condition  in  which  the  blood  from  the  congested  mucous 
membrane  of  the  tube  is  detained  and  dilates  it.     It  is  often  associ- 

1  See  also  the  chapter  on  Abdominal  Section  in  the  Appendix. 


PAROVARIUM. 


199 


ated  with  retention  of  menstrual  blood  in  the  uterus  (v.  Atresia 
Vaginae,  Section  VI.).  Diagnosis  is  difficult ;  Bandl  records  one  case 
where  he  diagnosed  the  condition  as  a  fibroid ;  and  Lawson  Tait,  one 
simulating  a  parovarian  cyst,  in  which  he  did  abdominal  section  and 
removed  six  quarts  of  thick  dark  brown  fluid. 

NEW    FORMATIONS  :    TUBO-OVARIAN    CYSTS. 

The  most  important  new  formations  are   connective-tissue  growths,  New  For- 
fibroma,    lipoma,    primary   tuberculosis,    carcinoma.       In    tuberculosis matlons- 
of  the   Fallopian   tube,  Steven   has   found,  sparingly  distributed,  the 
bacillus  tuberculosis  recently  discovered  by  Koch  in  tubercular  phthisis 
of  the  lungs  (Glas.  Med.  J.,  Jan.  1883).     In  46  cases  of  tuberculosis  of 
the  female  genital  organs,  the  tubes  were  affected  in  34  (Mosler). 

Tubo-ovarian  cysts  result  from  adhesions  between  the  fimbriated  end 
of  the  Fallopian  tube  and  the  ovary,  with  degeneration  of  the  corpora 
lutea  of  the  Graafian  follicles  thus  enclosed.  The  contents  may  be 
poured  into  the  uterus  along  the  tube. 

PAROVARIUM. 

The  diagram  shewn  at  fig.   122,  taken  from  Doran's  interesting  andParo- 

varium. 


F.T. 


FIG.  122. 
DIAGRAM  OF  THE  STRUCTURES  IN  AND  ADJACENT  TO  THE  BROAD  LIGAMENT  (Doran). 

1.  Framework  of  the  parenchyma  of  the  ovary,  seat  of  a  simple  or  glandular  multilocular  cyst.  2. 
Tissue  of  hilum,  with  3,  papillomatous  cyst.  4.  Broad  ligament  cyst,  independent  of  paro- 
varium  and  Fallopian  tube.  5.  A  similar  cyst  in  broad  ligament  above  the  tube,  but  not 
connected  with  it.  6.  A  similar  cyst  developed  close  to  7— ovarian  fimbria  of  tube.  8.  The 
hydatid  of  Morgagni.  9.  Cyst  developed  from  horizontal  tube  of  parovarium.  Cysts  4,  5,  6,  S, 
and  9  are  always  lined  internally  with  a  simple  layer  of  endothelium.  10.  The  parovarium  ;  the 
dotted  lines  represent  the  inner  portion,  always  more  or  less  obsolete  in  the  adult.  11.  A  small 
cyst  developed  from  a  vertical  tube ;  cysts  that  have  this  origin,  or  that  spring  from  the 
obsolete  portion,  have  a  lining  of  cubical  or  ciliated  epithelium,  and  tend  to  develop  papillo- 
matous growths,  as  do  cysts  in  2— tissue  of  the  hilum.  12.  The  canal  of  Gartner,  often  persistent 
in  the  adult  as  a  fibrous  cord.  13.  Track  of  that  duct  in  the  uterine  wall ;  unobliterated 
portions  are,  according  to  Coblenz,  the  origin  of  papillomatous  cysts  in  the  uterus. 


200  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

valuable  work,  shews  that  the  Parovarium,  which  is  the  remains  of  the 
Wolffian  bodies,  consists  of  a  horizontal  tube  and  8  or  10  well-developed 
vertical  tubes  with  5  or  6  in  addition  represented  only  by  fibrous 
threads.  The  horizontal  tube  may  be  traced  (12,  Fig.  122)  to  the  side 
of  the  uterus  forming  the  canal  of  Gartner  already  alluded  to  (page  23). 
It  is  important  to  observe  that  the  vertical  tubes  become  lost  in  the 
hilum  of  the  ovary ;  the  significance  of  this  will  be  referred  to  under 
ovarian  tumours.  The  tubes  are  lined  with  cubical  or  broken-down 
epithelium,  and  may  give  rise  to  the  tumours  known  as  parovarian 
(9,  11,  Fig.  122). 

This  form  of  tumour  is  usually  produced  by  the  distension  of  one  or 
more,  usually  one,  of  the  tubules ;  its  mode  of  production  may  however 
be  like  that  of  papillomatous  ovarian  tumours  in  which  true  tumour- 
growth  takes  place.  The  diagnosis  and  treatment  of  parovarian 
tumours  will  be  best  considered  along  with  those  of  ovarian  (v.  Chaps. 
XXIII.  and  XXIV.). 


CHAPTER    XX. 

MALFORMATIONS  OP  OVARY:   OVARITIS:  PERI- 
OVARITIS:    DISPLACEMENTS  OF  OVARY-HERNIA, 
PROLAPSUS. 

LITERATURE. 

Barnes — Diseases  of  Women,  p.  297 :  Lond.  1878.  On  Hernia  of  the  Ovary,  and 
Observations  on  the  Physiological  Relations  of  the  Ovary  :  Am.  J.  of  Obst.  XVI. 
p.  1,  1883.  Engelmann — The  dry  Treatment  in  Gynecology :  Amer.  Jour,  of  Obst. , 
June  and  July  1887.  Englisch— Oesterr.  Med.  Jahrbuch,  1871,  p.  335  ;  or,  Sydenham 
Year  Book,  1871-72,  p.  293.  Freund — Die  Lage  und  Entwickelung  der  Beckenor- 
gane  :  Breslau,  1863.  Herman — Prolapse  of  the  Ovaries  :  Med.  Times  and  Gazette, 
22d  October  1881.  His — Die  Lage  der  Eierstocke  in  der  weiblichen  Leiche  :  Archiv 
fiir  Anatomic  und  Physiologic,  Anat.  Abtheilung,  1881.  Klob — Pathologische 
Anatomic  der  weiblichen  Sexualorgane :  "VVien,  1864.  Lebedinsky — Ovarien  bei 
Scharlach :  Centralb.  f.  Gyn.  I.  Munde — Prolapse  of  the  Ovaries :  Am.  Gyn.  Tr., 
1879,  p.  164.  Olshausen — Die  Krankheiten  der  Ovarien :  Billroth's  Handbuch, 
Stuttgart,  1879.  Schroeder — Die  Krankheiten  der  weiblichen  Geschlechtsorgane  : 
Leipzig,  1878,  S.  341.  Schultze — Zur  Kenntniss  von  der  Lage  der  Eingeweide  im 
weiblichen  Becken  :  Arch.  f.  Gynak,  Bd.  ix.  S.  262.  Slavjansky — Die  Entziindung 
der  Eierstocke  :  Arch.  f.  Gyn.  Bd.  iii.  S.  183.  Tait,  Lawson — The  Pathology  and 
Treatment  of  Diseases  of  the  Ovary :  Birmingham,  1883. 

WE  first  take  up  some  preliminary  considerations. 

Palpation  of  Normal  Ovaries. — After  the  student  has  had  practice  in  Examina- 
the  Binianual,  he  will  probably  meet  with  some  favourable  case  where 
he  is  able  to  feel  the  normal-sized  ovary.  This  is  best  done  as  Schultze 
recommends.  To  map  out  the  right  ovary,  use  the  index  and  middle 
fingers  of  the  right  hand  internally  and  the  left  hand  externally  ;  for  the 
left  ovary,  the  left  hand  is  used  internally  and  the  right  externally. 
The  patient  should  lie  on  her  back,  with  the  knees  drawn  up  and  the 
legs  rotated  outwards.  This  rotation  of  the  knees  renders  the  psoas 
muscles  tense,  thus  making  their  inner  edges  (which  Schultze  gives  as 
a  guide  to  the  position  of  the  ovaries)  more  easily  palpable.  Normally, 
they  lie  at  about  the  level  of  the  pelvic  brim,  half  way  between  the 
Fallopian-tube  angle  of  the  uterus  and  the  psoas  (v.  pp.  25,  57,  58). 

Another  method  of  palpating  the  ovaries  is  to  draw  down  the  uterus 
with  the  volsella,  and  make  the  examination  with  the  finger  per  rectum. 

MALFORMATIONS   OF   OVARY. 

Absence  of  one  or  both  ovaries  or  rather  their  very  rudimentary  Malforma- 
development,  is  generally  only  part  of  maldevelopment  of  the  uterus,  ovary. 


202  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 


Ovaritis. 


Patho- 
logical 
Anatomy. 


Etiology. 


Occasionally  a  third  ovary  is  present — a  fact  worth  keeping  in  mind  in 
relation  to  Battey's  operation  (Chap.  XXI.). 

OVARITIS. 
SYNONYM — Oophoritis. 

NATURE — An  acute  or  chronic  inflammation  of  the  ovary. 
Simple  Hypercemia  of  the  Ovary  may  also  occur. 

PATHOLOGICAL   ANATOMY. 

Acute  ovaritis. — Of  this  we  recognise  two  forms  corresponding  to  the 
two  subdivisions  of  ovarian  tissue — the  follicular  or  parenchymatous, 
and  the  interstitial. 

In  the  follicular  form,  the  ovary  is  not  much  enlarged ;  but  we  find 
on  microscopical  examination  the  peripheral  follicles  increased  in  size, 
their  contents  turbid  or  purulent,  the  cells  of  the  membrana  granu- 
losa  and  the  ovum  in  a  state  of  cloudy  swelling.  The  zona  pellucida 
becomes  thickened  and  folded.  Usually  the  surrounding  tissue 
participates,  though  to  a  less  marked  degree,  in  the  inflammatory 
changes ;  and  in  marked  cases  the  germ-epithelium  becomes  cloudy 
and  broken  down,  with  fibrinous  deposits  on  its  surface. 

Lebedinsky  has  examined  the  changes  in  the  ovary  in  scarlet  fever. 
To  the  naked  eye,  there  was  no  difference ;  but  on  microscopic  examina- 
tion, the  Graafian  follicles  were  found  altered  with  cloudy  swelling  or 
destruction  of  the  epithelium.  The  younger  follicles  were  most 
markedly  affected,  but  the  stroma  was  unaltered.  In  this  way  the 
follicles  become  destroyed  and  cicatrized,  and  the  ovarian  function  thus 
greatly  impaired. 

In  the  interstitial  form,  the  ovary  is  increased  in  size  and  its  con- 
nective-tissue elements  are  proliferated.  Pus  may  form,  and  often  there 
are  small  apoplexies.  Slavjansky  speaks  of  the  following  varieties 
of  the  interstitial  form :  serous,  suppurative,  hsemorrhagic,  and 
necrotic. 

Chronic  ovaritis. — As  the  result  of  this,  we  get  destruction  of  the 
follicles  and  a  cirrhotic  condition  of  the  organ,  as  was  found  in  a  case 
of  Tait's  examined  by  Doran.  To  the  naked  eye,  the  ovaries  appeared 
markedly  fissured  on  the  surface.  Occasionally  the  ovary  remains 
distinctly  larger.  Whether  or  not  we  get  a  super-involution  of  the 
uterus  as  the  result  of  severe  and  double  ovaritis,  is  not  as  yet  settled. 
The  ovaries  may  be  small  and  cystic,  and  according  to  Tait  this  form 
gives  rise  to  severe  menorrhagia. 

ETIOLOGY. 
The  causes  of  ovaritis  are  the  following  : — 

o 

1.  Chill  at  menstrual  period  ; 


0  VARITIS.  203 

2.  Gonorrhoea,  latent  gonorrhoea  in  the  male  ; 

3.  Instrumental  exploration  of  the  uterus  ; 

4.  Childbirth  and  abortion  ; 

5.  Acute  febrile  disease  ; 

6.  Pelvic  peritonitis. 

Gonorrhoea. — The  ovaries  maybe  inflamed  sympathetically,  just  as  the 
testicles  are  in  gonorrhoea  of  the  male. 

Instrumental  exploration. — Sometimes  after  the  passage  of  the  uterine 
sound,  especially  in  difficult  cases,  the  ovary  becomes  tender. 

Childbirth  and  abortion. — This  is  a  common  cause  of  ovaritis.  Thus, 
in  27  cases  at  Halle,  Olshausen  found  the  ovaries  affected  in  13. 
Usually  both  ovaries  are  implicated. 

Acute  febrile  diseases. — Cholera,  the  exanthemata,  septicaemia,  and 
phosphorus  and  arsenic  poisoning  have  ovaritis  as  one  of  their  results. 

Pelvic  peritonitis. — It  will  readily  be  understood  that  ovaritis  often 
occurs  as  part  of  general  pelvic  peritonitis. 

The  follicular  'form  usually  occurs  in  febrile  diseases  and  pelvic 
peritonitis ;  the  interstitial  form  is  generally  puerperal. 

SYMPTOMS    AND    PHYSICAL    SIGNS. 

Acute  ovaritis. — A  case  of  simple  acute  ovaritis  is  not  common.     The  Symptoms 
patient  usually  complains  of  pain  at  the  side  radiating  to  the  back,  andan 
of  pain  on  pressure  in  the  iliac  regions. 

When  the  Bimanual  is  made,  the  ovary  or  ovaries  are  unusually 
accessible,  and  are  felt  as  mobile,  tender,  and  somewhat  enlarged 
bodies,  often  about  the  size  of  a  walnut;  and  pressure  causes  great 
pain  of  a  sickening  character.  Owing  to  adhesions,  the  mobility  may 
be  wanting. 

Chronic  ovaritis. — The  symptoms  and  physical  signs  are  as  in  the 
acute  form,  but  much  less  marked  and  with  a  chronic  history.  Men- 
orrhagia  is  often  present.  Sympathetic  pain  is  sometimes  felt  below  the 
left  mamma.  In  some  cases  a  form  of  epilepsy  is  brought  on  (menstrual 
epilepsy),  menstruation  being  in  abeyance. 

DIFFERENTIAL    DIAGNOSIS. 

When  the  ovary  is  not  fixed,  there  is  nothing  else  with  which  it  can  Differ- 
be  confounded.  ggj^ 

PROGRESS   AND    RESULTS. 

We  may  have  resolution  of  the  affection,  adhesion,  suppuration,  and  Progress 
abscess.  Sterility  is  a  frequent  result  of  double  ovaritis ;  hysteria  is  Results, 
often  present. 

TREATMENT.  Treatment 

Acute  ovaritis. — A  fly  blister  should  be  applied  over  the  appropriate  Acute. 


204  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

iliac  region,  and  the  hot  vaginal  douche  frequently  used.     Bromide  of 
potassium  may  be  given  as  follows. 

R.  Potassii  Bromidi  gr.  xxx  to  3i. 

Fiat  pulv  :         tales  xii. 
Sig.  One  powder  at  night. 

Treatment      Chronic  ovaritis — The   hot  douche  and  occasional  blisters  are   best. 

Chronic.     The  glycerine  plug  is  of  value. 

Glycerine  A  glycerine  plug  is  made  as  follows:  Take  a  square  piece  of  absorbent 
cotton  wool  about  the.  size  of  the  palm  of  the  hand  ;  pour  on  its  centre 
about  §ss.  glycerine ;  turn  the  corners  over  and  squeeze  the  whole  so  as  to 
saturate  it;  lastly,  tie  a  piece  of  thread  about  8  inches  long  round  it.  Pass 
Sims'  or  Fergusson's  speculum,  and  place  the  plug  in  the  fornix  below 
the  ovary.  It  should  be  left  in  for  18  to  24  hours,  and  then  withdrawn. 
This  plug  reduces  congestion,  owing  to  the  affinity  of  glycerine  for 
water;  has  an  antiseptic  action;  and,  as  we  shall  afterwards  see,  forms 
an  admirable  pessary.  It  sets  up  a  watery  discharge,  so  that  the  patient 
should  be  told  to  wear  a  diaper. 

A  tampon  of  non-absorbent  cotton  wool  dipped  in  bismuth  or  any 
mild  antiseptic  powder  may  be  substituted  for  the  glycerine  tampon. 
It  is  passed  with  the  aid  of  a  speculum,  and  should  be  smeared  at  its 
upper  part  with  vaseline.  It  does  not  become  hard  like  the  glycerine 
plug,  and  the  elasticity  of  the  non-absorbent  wool  is  of  benefit. 
The  following  mixture  is  of  use. 

R.  Potassii  Bromidi  3ij. 

Potassii  lodidi  3j- 

Inf.  Gentian.  Co.  gvi. 

Sig.  Tablespoonful  thrice  daily. 

In  menorrhagia  uncontrollable  by  ordinary  means,  oophorectomy  may 
be  performed  (Chap.  XXI.). 

PEBIOVABITIS. 

Peri-  By  this  we  understand  an  inflammatory  affection  of  the  tissues  sur- 

ltl8-      rounding  the  ovary,  which  fixes  the  organ.     It  is  a  convenient  clinical 

term  for  local  peritonitic  inflammations  at  the  site  of  one  of  the  ovaries. 

It  is  higher  up  than  the  usual  cellulitic  deposit.     The  treatment  is  the 

same  as  in  chronic  ovaritis. 

DISPLACEMENTS  OP  THE  OVARY— HERNIA. 

Herma  of        The   term  Hernia  is   limited   to  those  cases  where  the  ovaries  are 
f-  present  in  the  inguinal  canals,  in  the  obturator  foramen  (rare),  or  as 
part  of  an  abdominal  hernia.     Percival  Pott's  case,  where  this  first  con- 
dition existed  and  where  he  excised  both  of  the  displaced  organs,  is  the 


PROLAPSUS  OF  THE   OVARY.  205 

classical  instance  of  this  displacement.     The  usual  form  is  where  they 
are  present  in  the  inguinal  canal. 

ETIOLOGY. 

Ovaries  in  the  inguinal  canal  are  usually  congenital,  having  descended  Etiology, 
along  the  unobliterated  process  of  peritoneum.    In  17  cases  out  of  23  cases, 
Englisch  found  it  to  be  congenital ;  and  in  one-third  of  these,  the  hernia 
was  double. 

DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS. 

An  oval  tumour  of  the  size  of  the  ovary,  tender  on  pressure,  is  found  Diagnosis, 
in  the  inguinal  canal.     Its  connection  with  the  uterus  may  be  demon- 
strated by  drawing  the  latter  down  with  a  volsella. 

It  requires  to  be  diagnosed  from  an  ordinary  hernia,  and  from  hydro- 
cele  of  the  round  ligament. 

TREATMENT. 

A  protecting  shield  may  be  worn ;  and  where  very  troublesome,  the  Treatment, 
ovaries  may  be  cut  down  upon  and  removed.      Reduction  is  usually 
impossible,  owing  to  adhesions. 

PROLAPSUS. 

We  have  already  considered  the  support  of  the  ovary.     Its  attach- Prolapse  of 
ments  to  the  broad  ligament,  to  its  own  special  ovarian  ligament,  and  to    vary' 
the  ovarian  fimbria  of  the  Fallopian  tube,  assist,  but  its  chief  support  is 
the  infundibulo-pelvic  ligament  of  the  Fallopian  tube;  in  addition,  its  own 
specific  gravity  has  an  influence  in  determining  its  level.     Its  position 
is  constantly  changing.     As  the  bladder  fills,  it  is  displaced  backwards, 
and  its  lower  end  rises ;  during  pregnancy,  it  is  drawn  upwards  out  of 
its  pelvic  position  and  somewhat  enlarged.     The  ovary  is  thus  an  organ 
liable  to  displacement,  of  which  the  most  important  is  the  downward 
one — known  as  prolapse  of  the  ovary. 

PATHOLOGICAL  ANATOMY. 

The  ovary  lies  lower  than  usual,  in  the  lateral  or  in  the  true  pouch  Patho- 
of  Douglas;  the  uterus  may  be  in  its  normal  position,  but  oftener  it 
retroverted.     The  ovary  is  usually  enlarged,  and  often  fixed  by  peritonitic 
adhesions. 

Munde  considers  the  varieties  of  prolapsus  as — 
(1.)  Retro-lateral,  in  the  lateral  pouch  of  Douglas; 
(2.)  Retro-uterine,  in  the  true  pouch  of  Douglas; 
(3.)  Ante-uterine,  in  the  utero-vesical  pouch,  very  rare ; 
(4.)  In  the  infundibulum  of  an  inverted  uterus. 


206  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

ETIOLOGY. 

Etiology.  The  conditions  present  in  the  puerperium  favour  displacement  of  the 
ovary  for  two  reasons;  the  normal  ascent  of  the  uterus  during  pregnancy 
may  stretch  the  ovarian  and  infundibulo-pelvic  ligaments,  and  the  ovary 
may  not  return  to  its  normal  size  after  parturition.  Simple  congestion 
of  the  organ  may  cause  it  to  descend;  and  it  is  alleged  that  sudden  jolts 
may  also  drive  it  below  its  normal  site.  It  is  not  quite  certain  whether 
the  congestion  is  cause  or  result.  Probably  it  is  the  cause;  but  it  is 
also  aggravated  by  the  displacement. 

SYMPTOMS. 

Symptoms.  These  are  radiating  pains,  pain  on  defsecation  and  coitus,  a  dragging 
sensation,  reflex  nervous  symptoms  with  general  irritability. 

PHYSICAL    SIGNS. 

Physical  Bimanually,  we  feel  in  the  true  or  in  the  lateral  pouch  of  Douglas  a 
small  body  or  bodies,  exquisitely  tender  and  lying  distinct  from  the 
uterus.  By  the  rectal  examination,  the  ovary  is  felt  with  unusual 
distinctness.  Great  care  must  be  taken  to  be  gentle  in  examination. 
Cystic  small  ovaries  are  often  adherent,  the  adhesion  being  probably 
caused  by  rupture  of  the  cysts  which  may  be  done  by  even  gentle  mani- 
pulation and  cause  aggravation  of  symptoms  and  fresh  adhesions. 

TREATMENT. 

Treatment.  Blisters  over  the  iliac  region,  hot  vaginal  douche,  and  bromide  of 
potassium  in  fifteen-grain  doses  thrice  daily.  The  bowels  are  to  be 
opened  by  means  of  saline  purgatives,  such  as  the  Friedrichshall  water 
or  Carlsbad  salts.  The  following  mixture  is  good  : — 

R.  Magnesise  Sulphatis  3\-j. 

Quinina3  Sulphatis  gr.  xxiv. 

Acidi  Sulph.  dil.  3iij. 

Tinctures  Capsici  3j. 

Aquam  ad  gvj. 
Sig.  Tablespoonful  thrice  daily. 

This  relieves  the  congestion  by  unloading  the  bowels. 

A  course  of  treatment  at  Kreuznach  or  other  German  Spa  is  often  of 
service. 

Often  the  prolapsed  and  non-fixed  organ  becomes,  after  a  week  of  this 
treatment,  distinctly  higher  in  position.  The  glycerine  plug  or  dry 
tampon  is  then  of  the  utmost  value. 

In  the  chronic  stage,  when  the  uterus  is  retroverted  and  not  fixed, 
the  ring  or  the  Albert  Smith  pessary  is  good  (v.  Eetro version  of  Uterus). 


PROLAPSUS  OF  THE  OVARY.  207 

The  cases  where  the  tender  ovaries  are  fixed  low  down  by  adhesions 
are  exceedingly  difficult  to  treat.  When  the  uterus  is  retroverted  and 
fixed  and  the  ovaries  below  it,  we  get  one  of  the  most  troublesome  cases 
possible.  Palliative  treatment  by  blisters  and  the  hot  douche  is  best; 
if  the  case  is  not  amenable  to  this  treatment  and  the  patient's  general 
health  is  suffering,  the  propriety  of  Battey's  operation  should  be  con- 
sidered. 

Prolapse  of  the  ovaries  and  their  fixation  are  contra-indications  to 
treatment  indicated  otherwise — such  as  Emmet's  operation. 


CHAPTER  XXI. 

OPERATIONS  FOB  REMOVAL  OP  FALLOPIAN  TUBES 
AND  OVARIES. 

IN  this  chapter  we  have  to  consider  two  operations  :  "  Removal  of  the 
uterine  appendages,"  in  which  both  Fallopian  tubes  and  ovaries  are 
taken  away ;  and  "  Oophorectomy,"  in  which  the  ovaries  alone  are 
removed.  The  latter  operation  was  the  earlier  of  the  two  and  will 
therefore  be  considered  first. 

History  of  The  real  history  of  these  operations  dates  from  August  17th,  1872, 
when  Battey  of  Rome,  Georgia,  U.S.A.,  successfully  removed  the 
ovaries  of  a  patient  who  suffered  from  intolerable  dysmenorrhoea.  On 
July  27th  of  the  same  year,  Hegar  of  Freiburg  had  removed  both 
ovaries  in  a  case  of  severe  ovarian  neuralgia  :  the  patient  died,  and 
Hegar  did  not  publish  an  account  of  the  case.  Lawson  Tait  removed 
the  ovaries  for  pain  in  October  1871,  and  for  menorrhagia,  on  August 
1st,  1872,  both  successfully.  Bluudell  of  London  (1823),  with  that 
rare  medical  insight  and  experimental  knowledge  which  led  him  to 
advocate — if  not  to  practise — what  recent  obstetric  science  has  shown  to 
be  a  valuable  mode  of  performing  the  Csesarean  Section,  had  already 
thrown  out  the  suggestion  that  the  ovaries  should  be  removed  in 
dysmenorrhoea  and  to  arrest  haemorrhage  in  inverted  uterus.  To 
Battey,  however,  is  due  the  honour  not  only  of  conceiving  the  idea, 
but — what  was  more  difficult — of  successfully  carrying  it  into  execu- 
tion and  impressing  the  profession  with  its  importance  and  value  in 
special  cases.  The  same  honour  is  due  to  Tait,  with  regard  to  his 
operation  for  removing  the  uterine  appendages. 

OOPHORECTOMY  (BATTEY'S  OPERATION). 

LITERATURE. 

The  literature  on  this  operation  is  too  extensive  to  be  given  in  detail  in  a  student's 
manual.  The  best  summaries  of  cases  are  by  Engelmann,  Hegar,  and  Simpson. 
See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix.  Battey — 
Battey 's  Operation :  Transactions  of  International  Medical  Congress,  Lond.,  1881. 
See  Am.  J.  of  Obst.,  October  1881,  for  discussion.  See  also  Battey' s  Operation: 
American  System  of  Gynecology  edited  by  Mann,  Vol.  II.,  p.  837.  By  ford— 
Removal  of  the  Uterine  Appendages,  etc.,  by  Vaginal  Section :  Am.  Journ.  of  Obstet., 
1888,  pp.  337  and  872.  Engelmann— The  Difficulties  and  Dangers  of  Battey's  Opera- 
tion: Am.  Med.  Asso.  Trans.,  1878  (date  of  reprint).  Battey's  Operation,  3  fatal 
cases :  Am.  J.  of  Obst.,  July  1878.  Hegar— Die  Castration  der  Frauen  :  Volkmann's 
Sammlung,  Nos.  136-138.  Simpson,  A.  .R.— History  of  a  Case  of  Double  Oopho- 
rectomy or  Battey's  Operation  :  Br.  Med.  J.,  May  24th,  1879.  Sims,  J.  Marion— 
Remarks  on  Battey's  Operation :  Br.  Med.  Journal,  1877. 


OOPHORECTOMY.  209 


NOMENCLATURE. 

We   have   adopted   the   term   Oophorectomy   as   a   convenient   andNomen- 
useful   one.      Other    terms,    however,    have   been    proposed.      Marion0  a  ure' 
Sims  suggested  that  it  should  be  called  Battey's  Operation  after  its 
originator,  and  this  name  has  been  widely  adopted.     "  Normal  Ovario- 
tomy "   is   a   misnomer,   inasmuch   as    the   ovaries   are    not    normal. 
"  Spaying,"  a  term  advocated  by  Goodell,  does  not  recommend  itself 
by  its  delicacy.     "Die  Castration  der  Frauen,"  the  German  name  for 
the  operation,  is  open  to  a  similar  objection. 

NATURE    AND    AIMS    OF    OPERATION. 

Oophorectomy  is  the  removal  of  diseased  ovaries  not  enlarged  by  Nature 
tumour-growth  but  causing  serious  symptoms   such  as   menorrhagia, an       ms' 
epilepsy,  severe  pain.     Battey  proposed  it  for  dysmenorrhoea,  on  the 
theory  that  it  would   bring   on   the   menopause   prematurely.     This, 
however,  does  not  occur  as  an  immediate  result.     More  recently,  Battey 
has  declared  that  he  operates  to  arrest  ovulation. 

INDICATIONS    FOR    OPERATION   AND    ITS    RESULTS. 

These  are  not  as  yet  strictly  determined;  i.e.,  so  far  as  our  present Indica- 
knowledge  goes,  the  operation  is  indicated  in  certain  conditions,  but  as 
yet  we  do  not  know  whether  in  all  of  them  it  produces  the  anticipated 
effect.     They  are  as  follows  : — 

(1.)  Intolerable  Dysmenorrhoea ; 

(2.)  Bleeding    from   Fibroid   Tumours,    uncontrollable    by 

other  means ; 
(3.)  Hystero-epilepsy,  convulsions  and  threatened  insanity, 

dependent  on  ovarian  irritation  or  presence  of  ovaries 

with  absence  of  uterus ; 
(4.)  Prolapsed  and  fixed  ovaries. 

(1.)  Dysmenorrhoea. — In  those  cases  where  the  patient  has  intolerable 
and  prolonged  pain  every  month,  wearing  her  down  and  rendering 
habitual  recourse  to  opiates  necessary,  the  operation  may  be  performed. 
It  should  not  be  forgotten  that  the  results  in  such  cases  are  not  so  bril- 
liant as  was  once  expected.  The  menstruation  is  not  at  first  entirely 
arrested  by  the  removal  of  the  ovaries ;  and,  as  we  have  always  in  such 
cases  pelvic  peritonitis  adding  to  the  patient's  misery  and  untouched  by 
the  operation,  it  is  evident  that  we  must  not  expect  too  much  from  it. 
Lawson  Tait  believes  that  the  Fallopian  tubes  must  also  be  removed  in 
order  to  arrest  menstruation  completely. 

(2.)  Bleeding  from  fibroid  tumours,  uncontrollable  by  other  means. — It 
is  in  this  condition,  for  which  Battey's  operation  was  first  advocated  by 


210  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

Treiiholm  and  Hegar,  that  the  most  brilliant  successes  have  been  won. 
Not  only  has  hemorrhage  been  checked,  but  the  tumours  themselves 
have  diminished  in  size  and  even  in  some  cases  disappeared. 

(3.)  In  some  cases  of  hystero-epilepsy,  convulsions,  insanity,  and  dandn<j 
mania,  dependent  on  ovarian  irritation,  the  operation  has  been  performed 
with  but  moderate  success.  Engelmann,  Gilmore,  A.  R.  Simpson,  and 
Battey,  quote  some  remarkable  cases. 

(4.)  In  cases  of  ovaries  prolapsed  or  fixed  by  adhesions,  and  giving  rise 
to  intolerable  pain  in  coitus  or  seriously  affecting  the  patient's  health, 
their  removal  is  called  for. 

At  the  London  International  Congress  the  operation  was  discussed. 
According  to  Battey,  the  mortality  has  been  22  per  cent,  for  incomplete 
operations,  and  9 £  per  cent,  for  complete ;  for  the  complete  operations, 

the  results  as  to  relief  have  been — 

No.  Per  Cent. 

Cured,  .  .  .  .68  77 

Greatly  benefited,      .  .  .15  17 

Not  benefited,  .          '  .  7 

Of  the  incomplete  operations — 

No.  Per  Cent. 

Cured,  .  .3  18 

Greatly  benefited,      .  7  41 

Not  benefited,  '..  .          '  .  7  41 

Battey's  statistics  (1888)  in  private  practice  have  been  as  follows  : 
Fifty-four  cases — cured  33,  much  improved  8,  little  improved  5,  not 
improved  8.  Complete  menopause  followed  in  50  and  pseudo-menstruation 
in  4. 

METHOD    OP    PERFORMING    THH    OPERATION. 

Operation.  The  ovaries  may  be  removed  (1.)  by  the  vaginal  method,  or  (2.)  by 
abdominal  section.  As  the  former  is  the  less  usual  method,  we  shall 
describe  it  but  shortly. 

Vaginal  (1.)  The  vaginal  method.     Give  chloroform.     Place  the  patient  semiprone  or,  better,  in 

Method.  the  lithotomy  posture.  Pass  Battey's  speculum,  lay  hold  of  cervix  uteri  with  a  volsella 
and  draw  it  down.  Wash  out  the  vagina  thoroughly  with  a  douche. 

Now  incise  the  posterior  vaginal  wall,  behind  the  cervix,  in  the  middle  line  for  about 
an  inch  and  a  half.  Open  into  the  peritoneal  cavity,  pass  in  the  index  finger  or  long 
polypus  forceps,  and  hook  down  the  nearer  ovary  ;  supra-pubic  pressure  is  made  by  an 
assistant.  Ligature  the  ovary  at  the  hilum  with  thin  carbolized  silk  threaded  on  a  fixed 
needle.  The  hilum  is  transfixed  mesially  with  the  needle,  the  double  ligature  drawn 
through  and  cut,  one  thread  is  tied  round  the  one-half  of  the  base  and  the  other  round 
the  other  half ;  the  ovary  is  then  cut  off,  and  the  ligature  cut  short.  The  other  ovary  is 
treated  in  the  same  way  ;  we  make  certain  that  there  is  not  a  third  ovary  which  would 
likewise  require  to  be  ligatured.  Battey  passes  a  temporary  ligature  round  the  base  of 
tho  ovary  and  then  uses  the  4craseur.  Lastly,  pass  in  a  drainage  tube,  stitch  the  wound 
(Battey  leaves  it  unstitched),  and  irrigate  twice  daily  with  weak  carbolic  solution  (1-100). 
After-treatment  as  in  ovariotomy  (v.  Chap.  XXIV.). 


OOPHORECTOMY.  211 

This  method  may  be  used  if  the  ovaries  are  low  down.  It  is  sometimes  difficult  to 
make  out  the  ovary,  and  even  impossible  to  remove  it.  In  one  case  Battey  had  to  dig 
out  portions  with  his  finger  nail ;  all  was  not  removed,  and  the  patient  conceived  some 
time  afterwards. 

(2.)  Removal  of  Ovaries  by  Abdominal  Section.  The  abdominal  walls  Abdo 
are  incised  and  the  peritoneal  cavity  opened  into  as  described  in  the 
Chapter  on  Abdominal  Section  in  the  Appendix.  The  fingers  are  passed 
in  so  as  to  touch  the  fundus  uteri ;  and  then  carried  along  the  Fallopian 
tube  so  as  to  recognise  the  ovary  usually  lying  behind.  It  should  be 
lifted  up  if  possible  to  the  incision,  and  ligatured  with  thin  carbolised 
silk  as  described  under  the  vaginal  method ;  the  ligatures  are  cut  short 
and  each  side  of  the  pedicle  held  with  Pean's  forceps.  Marion  Sims 
recommends  his  uterine  repositor  as  an  aid  to  the  elevation  of  the  ovaries. 
This  elevation,  however,  can  be  more  easily  managed  by  introducing  the 
two  fingers  or  whole  hand  into  the  vagina,  and  elevating  all  in  front  of 
the  posterior  vaginal  wall. 

A  very  good  knot  is  that  known  as  the  Staffordshire  Knot,  introduced 
for  this  and  similar  cases  by  Lawson  Tait.  The  hilum  is  tranfixed 


FIG.  123. 

STAFFORDSHIRE  KNOT  (Tait). 

This  shows  knot  after  loop  has  been  brought  over,  one  end  brought  above  it,  and  the  first  turn 
of  the  artery  knot  made. 

with  a  needle  and  silk  ligature ;  the  needle  is  then  withdrawn  and  the 
loop  on  the  distal  side  brought  over  the  ovary  and  carried  below  one  end 
of  the  thread  ;  the  two  ends  are  then  tied  over  the  loop  with  an  artery 
knot  (v.  fig.  123). 

The  ovary  is  then  cut  away  with  the  knife  at  a  point  about  half  an 
inch  clear  of  the  ligature.  The  other  ovary  is  treated  in  the  same  way. 
We  hold  the  pedicle  for  a  time  in  the  Pean's  forceps,  before  dropping  it 
back,  to  see  that  there  is  no  bleeding.  The  peritoneal  cavity  is  cleansed 
and  the  abdominal  incision  closed  as  in  any  other  case  of  abdominal 
section  (vide  Chapter  on  Abdominal  Section  in  the  Appendix). 

The  operation  is  by  no  means  always  an  easy  one.  The  skin  incision 
is  more  difficult  than  in  ovariotomy,  for  there  is  always  a  risk  of  wounding 
intestine.  In  some  cases,  Hegar  has  made  a  lateral  incision.  Sometimes, 
especially  in  cases  of  fibroids,  it  is  exceedingly  difficult  to  get  at  the 
ovaries.  Engelmann  has  more  particularly  directed  attention  to  this 
point.  In  one  of  his  cases  he  says : — The  ovaries  were  so  deeply  im- 
bedded within  the  folds  of  the  broad  ligaments,  and  with  them  so  firmly 


212  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

tied  down  to  the  sides  and  floor  of  the  pelvis  that  it  was  impossible  to 
move  them.  With  the  greatest  difficulty  several  unsatisfactory  ligatures 
were  placed  about  the  left  ovary;  but  it  was  useless  even  to  attempt  to 
tie  the  right,  so  intimately  was  it  blended  with  the  broad  ligament,  and 
so  immovably  adherent  to  the  pelvic  walls.  ...  I  enlarged  the 
incision  to  two  inches  above  the  navel,  removed  the  intestine  from  the 
pelvic  cavity,  and  then  succeeded  in  enclosing  the  entire  mass  in  the 
ligature,  and  removing  the  ovaries  complete."  Kaltenbach  in  one  case 
ruptured  the  Fallopian  tube  dilated  with  pus  ;  the  patient  died  of  septic 
peritonitis.  Freund,  Martin,  Sims,  and  Battey  have  also  recorded  difficult 
cases. 

GENERAL  CONCLUSIONS. 

Conclu-  Agnew  in  his  works  on  Surgery  gives  a  list  of  171  cases  of  ob'phor- 
ectomy  (up  to  1886)  with  18'72  per  cent,  deaths.  Of  these,  144  were 
performed  by  abdominal  section  and  27  by  the  vaginal  method — with 
about  equal  mortality.  The  most  brilliant  results  are  in  fibroids  : 
those  in  dysmenorrhcea  and  nervous  conditions  are  doubtful. 

Some  interesting  physiological  points  have*  been  brought  out : 
removal  of  the  ovaries  does  not  bring  on  the  menopause,  sexual  appetite 
is  not  diminished,  and  no  womanly  attributes  are  in  any  way  removed. 
The  outcry  that  it  unsexes  a  woman  is  absurd.  The  ovaries  removed 
were  probably  useless  for  procreation ;  and  when  their  presence  is  causing 
serious  illness,  they  are  better  removed. 

REMOVAL  OF  UTERINE  APPENDAGES 
(TAIT'S  OPERATION). 

LITERATURE.  Bertram — Laparotomie  bei  Tumoren  der  Tuba  Fallopii :  Berliner  KLinische 
Wochenschrift,  Jany.  22,  1883.  Savage — Diseases  of  the  Fallopian  Tubes :  Birm. 
Med.  Rev.,  Jan.  1883.  Tait,  Lawson — The  Diagnosis  and  Treatment  of  Chronic 
Inflammation  of  the  Ovary  :  Br.  Med.  Jour.,  July  29,  1882.  An  Account  of  208 
consecutive  cases  of  Abdominal  Section  performed  between  Nov.  1,  1881,  and  Dec. 
31,  1882 :  Br.  Med.  Jour.,  Feb.  17,  1883.  Recent  Advances  in  Abdominal  Surgery  : 
Int.  Med.  Cong.  Tr.,  Lond.,  Vol.  II.,  p.  228.  The  Modern  Treatment  of  Uterine 
Myoma :  Brit.  Med.  Journal,  August  15,  1885.  Removal  of  Uterine  Appendages 
for  the  Arrest  of  Uterine  Haemorrhage :  Am.  Journal  of  Med.  Science,  1882. 
Thomas,  T.  G. — A  Contribution  to  the  Subject  of  the  Removal  of  the  Uterine 
Appendages  (Tait's  Operation)  for  Prolonged  Menstrual  Troubles  with  Recurrent 
Pelvic  Inflammations :  N.  Y.  Med.  Jour.,  Jan.  13,  1883.  See  also  Index  of  Recent 
Gynecological  Literature  in  Appendix  for  numerous  papers  giving  latest  results  of 
various  operators. 

Removal     WE  have  ah-eady  seen  that  Battey's  idea  of  bringing  on  a  premature 
Append-116  menopause  by  removal  of  the  ovaries  has  not  been  found  to  be  correct 
ftges-          although  this  in  no  way  detracts  from  the  great  honour  due  to  his 
courage. 

Lawson  Tait  believes  that  removal  of  the  Uterine  Appendages  will 
arrest  menstruation,  and  that  therefore  in  certain  cases  of  bleeding 
Fibroids  we  have  a  sure  and  safe  means  of  controlling  haemorrhages  and 


OPERATION.  213 

causing  atrophy  of  the  tumour.  Chronic  ovaritis  and  menstrual  epilepsy 
are  also  indications  although  the  results  as  to  cure  are  less  satisfactory 
in  the  latter.  Recently,  Johnstone  of  Danville,  Kentucky,  has  asserted 
that  to  arrest  menstruation  it  is  necessary  to  cut  a  comparatively  large 
nerve  trunk  which  runs  in  the  broad  ligament  up  to  the  angle  formed 
by  the  uterus  and  the  uterine  end  of  the  Fallopian  tube. 

Lawson  Tait,  as  we  have  seen,  removes  the  appendages  in  cases  of 
chronic  ovaritis,  pyosalpinx  and  hydrosalpinx.  In  these  cases,  however, 
the  tubes  are  removed  because  atrophied  or  purulent ;  and  the  ovaries 
are  removed  too,  inasmuch  as  besides  being  often  diseased  they  are  of 
course  useless  without  the  tubes.  In  the  case  of  Fibroids,  the  appendages 
are  removed  not  because  diseased  in  themselves  but  to  check  bleeding. 
How  they  do  this  is  not  yet  known.  It  is  not  by  cutting  off  the  blood 
supply,  as  the  ovarian  artery  is  not  removed ;  and  even  if  it  were,  the 
uterine  artery  is  sufficient  to  carry  on  the  circulation. 

For  the  details  of  the  operation,  the  student  is  referred  to  the  chapter 
on  Pyosalpinx,  and  to  Abdominal  Section  in  the  Appendix. 


CHAPTER  XXII. 

THE  PATHOLOGY  OF  TUMOURS  OF  THE  OVARY, 
PAROVARIUM,  AND  BROAD  LIGAMENT. 

LITERATURE. 

Bantock—On  the  Pathology  of  certain  (so-called)  Unilocular  Ovarian  Tumours :  Lond. 
Obst.  Jour.,  Vol.  I.,  p.  124.  .Barnes— Diseases  of  Women,  p.  322,  Lond.  1878. 
Beck,  Marcus — Nephritis  and  Pyelitis  subsequent  to  the  affections  of  the  lower 
urinary  tract :  Reynold's  System  of  Medicine,  Vol.  V.,  1879.  Coblenz— Zur  Genese 
und  Entwickelung  von  Kystomen  im  Bereich  der  inneren  weiblichen  Sexualorgane  : 
Virchow's  Archiv,  Bd.  84 ;  ibid.  Bd.  82.  See  alsoZtschriftfiir  Geburtshiilfe  undGyniik., 
Bd.  VII.  ;  and  Arch,  fiir  Gynak.,  Bd.  XVIII.  Coe — Fibromata  and  Cystofibromata 
of  the  Ovary  :  Am.  J.  of  Obst.,  XV.,  561.  Cullingworth — Fibroma  of  both  Ovaries  : 
Lond.  Ob.  Tr.,  XX.,  p.  276.  De  Sin6ty—(v.  Malassez).  Donat— Bin  Fall  von 
sogenanntem  Pseudomyxoma  Peritonei :  Archiv  fiir  Gynak.,  Bd.  XXVI.  Doran — 
Clinical  and  Pathological  Observations  on  Tumours  of  the  Ovary,  Fallopian  Tube 
and  Broad  Ligament:  London,  1884.  (Also  v.  Harris.)  Drysdale — On  the 
Ovarian  Cell  found  in  Ovarian  fluid  :  Trans.  Americ.  Med.  Ass.  (1873,  date  of 
reprint.)  Duplay — Des  Kystes  du  ligament  large  :  Arch.  Generales  de  Medecine, 
Oct.  1882.  Eichwald— Colloidentartung  der  Eierstocke  :  Wurz.  Med.  Z.,  B.V.  1864, 
p.  270.  Fischel — Ueber  Parovarialcysten  und  parovarielle  Kystome  :  Arch,  fiir 
Gynak.,  Bd.  XV.  S.  198.  Foulis— Cancer  of  the  Ovary :  Ed.  Med.  Jour.,  1875, 
p.  838.  The  Diagnosis  of  Malignant  Ovarian  Tumours,  and  Malignant  Peritonitis  : 
Brit.  Med.  Jour.,  1878,  pp.  91  and  658.  Fox,  Wilson—  On  the  Origin,  Structure, 
and  Mode  of  Development  of  the  Cystic  Tumours  of  the  Ovary  :  Lond.  Roy.  Med. 
and  Chir.  Tr.,  Vol.  XL VII.,  p.  227.  Gabbett— Colloid  Degeneration  of  the  non-cystic 
Ovary,  &c.  :  Journal  of  Anat.  and  Physiology,  Vol.  XVI.  Garrigues— Diagnosis  of 
Ovarian  Cysts  by  means  of  the  examination  of  the  Contents  :  Am.  J.  of  Obst.,  XV., 
p.  1.  Gusserow— Ueber  Cysten  des  breiten  Mutterbandes  :  Archiv  f.  Gynak.,  Bd. 
IX.,  S.  478.  Harris  and  Doran— The  Ovary  in  Incipient  Cystic  Disease  :  Jour,  of 
Anat.  and  Physiol.,  Vol.  XV.,  Pt.  IV.,  July  1881.  Howell,  S.  F.— Pathology  of 
Ovarian  Tumours  :  Amer.  Syst.  of  Gynec.  and  Obst.,  Vol.  II.,  p.  950.  Killian— 
Zur  Anatomic  der  Parovarialcysten  :  Arch,  fiir  Gynak.,  XXVI.,  S.  460.  Malassez  et 
.  De  Sinety—Su.r  la  Structure,  1'Origine  et  le  Development  des  Kystes  de  1'Ovaire  : 
Archiv.  de  Physiologic  Normale  et  Pathologique,  Vol.  V.,  1878,  p.  343.  Nceggerath 
—The  Diseases  of  Blood-vessels  of  the  Ovary  in  Relation  to  the  Genesis  of  Ovarian 
Cysts  :  Am.  Jour,  of  Obst.,  Vol.  XIII.,  1880.  Olshausen— Die  Krankheiten  der 
Ovarien  :  Billroth's  Handbuch  :  Stuttgart.  Patenko— Ueber  die  Entwickelung  der 
Corpora  Fibrosa  in  Ovarien :  Virchow's  Archiv,  Bd.  84,  1881.  Rindfteisch— Patho- 
logical Histology,  New  Sydenham  Society  Translation,  1873,  p.  171.  Schroeder— Die 
Krankheiten  der  weiblichen  Geschlechtsorgane  :  Leipzig,  1879.  Slatyansky—Zur 
normalen  und  pathologischen  Histologie  des  Graaf'schen  Blaschens  des  Menschen  : 
Virchow's  Archiv,  Bd.  51,  1870.  Button,  J.  Bland— An  introduction  to  General 
Pathology  :  J.  &  A.  Churchill,  London,  1886.  Tail— Diseases  of  the  Ovaries : 
Cornish,  Birmingham,  1883.  V.  Swiecicki  —  Zur  Casuistik  des  Pseudomyxoma 


PATHOLOGY  OF  OVARIAN  TUMOURS.  215 

Peritonei  ("Werth) :  Cent,  fur  Gynak.,  No.  44,  1885.  Waldeyer — Die  Eierstock- 
scystome:  Archiv  f.  Gynak.,  Bd.  1,  S.  252.  Wells,  Sir  T.  S. — Ovarian  and  Uterine 
Tumours  :  Churchill,  London,  1882.  Werth,  —  Ueber  Pseudomyxoma  Peritonei : 
Arch,  fiir  Gynak.,  Bd.  XXIV.  Williams — Ovarian  Tumours;  Reynold's  System 
of  Medicine,  Vol.  V.  Olshausen,  Schroeder,  and  "Williams  give  the  literature 
well.  Coe's  and  Cullingworth's  articles  give  the  literature  for  solid  tumours. 
See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

THE  somewhat  complex  subject  of  Ovarian  Tumours  will  be  best  con- Origin  of 

sidered  under  the  following  heads  : —  Ovarian 

Cysts. 

1.  Preliminaries; 

2.  The  mode  of  origin  of  ovarian  cysts  ; 

3.  Varieties     of    ovarian    cysts,   their    naked-eye     and    microscopic 

anatomy  ; 

4.  The  nature  of  ovarian  fluids  ; 

5.  Solid   ovarian    tumours,    malignant   tumours  and  the   nature   of 

the  ascitic  fluid  associated  with  them. 

PRELIMINARIES. 

We  must  first  consider  some  points  in  relation  to  the  development  of 
the  foetus,  and  the  anatomy  and  physiology  of  the  ovary  and  adjacent 
structures.  These  we  take  up  under  the  following  divisions  : — 

(1.)  Development  of  the  genito-urinary  organs; 
(2.)  Anatomy  of  the  ovary  ; 
(3.)  Physiology  of  the  ovary. 

(1.)  Development  of  the  genito-urinary  organs.     In  the  human  foetus  Develop- 
there  are  two  structures  from  which  the  future  urinary  and  sexual  organs  genito- 

are  to  be  developed  :  these  are  the  ducts  of  Mtiller  and  the  "VVolffian urinarv 

organs, 
bodies  (fig.  1,  PI.  XL).     In  the  female,  the  ducts  of  Muller  form  the 

Fallopian  tubes,  uterus  and  vagina ;  the  Wolffian  bodies  do  not  develop 
but  traces  are  found  normally  in  the  broad  ligament  forming  the  paro- 
varium,  while  we  may  have  further  traces  in  the  positions  shown  in 
fig.  122,  as  well  as  in  the  hilum  of  the  ovary. 

It  is  from  these  remnants  of  the  Wolffian  bodies  that  the  following 
cystic  tumours  are  developed ;  viz.,  papillomatous  cysts  of  the  hilum, 
parovarian  cysts,  cysts  of  the  broad  ligament,  and  what  Coblenz  terms 
para-uterine  cysts. 

(2.)  Anatomy  of  the  ovary.     In  regard  to  the  anatomy  of  the  ovary,  Anatomy 
we  must   note  two  great  divisions  of  it  :  viz.  the  Hilum  and  Paren-° 
chyma — the  former    containing  traces  of  the  Wolffian  bodies  and  the 
latter  the  characteristic  structures  known  as  the  Graafian  follicles  with 
their  ova  (fig.  122).     In  regard  to  the  development  of  these  follicles,  we 
have  already  seen  that  the  actively  growing  connective  tissue  of  the 
ovary  encloses  the  germ  epithelium ;  that  certain  of  the  germ  epithelial 


216  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

cells  thus  enclosed  develop  into  ova ;  while  the  connective  tissue  itself, 
according  to  Foulis,  forms  the  membrana  granulosa  (v.  Plate  X.,  fig.  F.). 
The  germ  epithelium  thus  enclosed  gave  rise  to  the  erroneous  idea  that 
the  developing  ovary  was  a  tubular  organ ;  and  to  the  epithelium  thus 
enclosed  (or  rather,  according  to  Pfliiger,  the  epithelium  penetrating 
into  the  ovarian  stroma)  was  given  the  name  of  Pfluger's  ducts. 

A  section  of  a  developed  ovary  shows,  further,  cellular  structures  (fig. 
1 24),  which  (according  to  Waldeyer)  are  some  of  Pfluger's  ducts  that  have 
not  developed  as  they  should  have  done  into  Graafian  follicles,  and  which 
may  give  origin  to  ovarian  cysts. 

It  must  also  be  remembered  that  we  have  in  the  ovary  a  great 
variety  of  tissue,  viz.,  fibrous  and  spindle-celled  connective  tissue,  and 
unstriped  muscle. 

Physiology      (3.)  Physiology  of  the  Ovary. — When  we  consider  that  every  month 

of  Ovary,    between  puberty  and  the  menopause  a  Graafian  follicle  distends  and  then 

ruptures,  we  are  led  to  expect  what  really  does  sometimes  occur,  viz., 


FIG.  124. 

CELLULAR  BODIRS  alleged  by  Waldeyer  to  be  enclosed  germ  epithelium  which  has  not  developed  into 
normal  Graafian  follicles.    He  believes  these  to  be  one  source  of  ovarian  tumours  (ficeggerath). 

that  the  follicle  may  not  rupture  but  merely  distend  to  form  a  patho- 
logical cyst.  When  pregnancy  occurs,  the  ruptured  follicle  has  its  large 
corpus  luteum  filling  it ;  and  in  this  also  we  may  have  pathological 
development.  Of  the  30,000  to  75,000  Graafian  follicles  contained  in 
each  ovary,  only  an  insignificant  number  develop  and  rupture  at  each 
menstrual  period.  Many  of  the  rest  atrophy,  forming  the  corpora  fibrosa 
which  are  seen  on  section  as  fibrous  points  and  contain  no  vessels ;  it  is 
alleged  that  these  corpora  fibrosa  may  originate  also  from  ripe  follicles 
or  from  follicles  where  there  has  been  haemorrhage. 

MODE   OF    ORIGIN    OF    OVAIIIAN    CYSTS. 

Mode  of         Ovarian  tumours  may  arise  from  the  following  sources  : — 

Origin  of  /i   \   T\-  a.      A-  i 

Ovarian  (*•)  Intention  and  coalescence  of  Graafian  follicles ; 

(2.)  Degeneration  of  undeveloped  Graafian  follicles  (ordinary  multi- 

locular  tumours) ; 
(3.)  Development  of  remnants  of  the  Wolffian  bodies  in  the  hilum 

of  the  ovary  (papillomatous  tumours)  ; 
(4.)  Malignant  development  of  the  connective  tissue  of  the  ovary. 


PLAIB  IX 


PATHOLOGY  OF  OVARIAN  TUMOURS.  217 

There  are  other  alleged  sources  for  which  the  evidence  is  not  as  yet 
sufficient :  viz., 

(5.)  Degeneration  of  blood-vessels ; 

(6.)  Certain  epithelial  tubes  running  into  the  ovary ; 

(7).   Colloid  degeneration  of  ovarian  stroma. 

(1.)  Distention   and  coalescence  of  Graafian  follicles. — There    can   be  Wilson 
no  doubt  that  small  cysts  may  so  originate.     The  proof  of  this  is  positive,   ox  a  view' 
as  Rokitansky  found  ova  in  cysts  about  the  size  of  a  bean.     Wilson  Fox 
has  attempted  to  show,  in  his  well-known  paper,  that  all  the  varieties  of 
cystic  tumours  may  be  formed  in  this  way. 

(2.)  Degeneration  of  undeveloped  Graafian  follicles  (ordinary  multilocular 
tumours). — This  is  probably  an  important  source  for  the  ordinary  multi- 
locular tumours.  The  normal  atrophic  changes  in  the  youngest  or 
primordial  follicles  have  been  traced  by  Slavjansky  and  Patenko,  whose 
researches  are  too  detailed  for  quotation  here.  Changes  in  the  normal 
retrogression  of  these,  viz.  active  ingrowth  of  the  ovarian  stroma  and 
breaking  down  of  the  relics  of  the  membrana  propria  of  the  follicle  are 
probably  important  in  bringing  about  the  cystic  changes. 

(3.)  Development  of  remnants  of  the  Wolffian  bodies  in  the  hilum  of  the 
ovary  (papillomatous  tumours}. — As  already  mentioned  when  speaking  of 
the  development  of  the  genito-urinary  system  (v.  p.  199),  remains  of  the 
Wolffian  bodies  persist  at  the  hilum  of  the  ovary.  Coblenz  believes  that 


FIG.  125. 

CELLULAR  BODIES  which  Nceggerath  believes  to  be  diseased  blood-vessels  and  not  germ  epithelium 
as  Waldeyer  asserts  (Nasggerath). 

when  ovarian  tumours  show  a  papillomatous   development,  they  have 
arisen  from  this  portion  of  the  ovary. 

(4.)  Malignant  development  of  connective  tissue  of  ovary. — In  malignant 
disease  of  the  ovary,  ascitic  fluid  is  often  formed  in  which  are  character- 
istic cells  first  described  by  Foulis  of  Edinburgh.  Plates  IX.  and  X. 
show  these.  They  will  be  considered  under  the  ascitic  fluid  associated 
with  malignant  tumours.  Foulis'  developmental  work  on  the  ovary  has 
valuable  bearings  on  its  pathology. 

(5.)  (6.)  (7.)  Degeneration  of  Uood-vessels  ;  certain  epithelial  tubes  running  into 
ovary  ;  colloid  degeneration  of  ovarian  stroma. — Nceggerath  of  New  York  first  pointed  ath's  view, 
out  that  diseased  blood-vessels  might  form  a  source  of  ovarian  cysts.     According  to  him 
(fig.  125),  we  have  disease  of  the  intima  of  the  vessel,  loss  of  its  endothelium,  and  per- 


218  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

eolation  of  the  contents  of  the  vessel  into  the  intima.  Migrating  cells  accumulate  in  the 
interstices  of  the  intima  and  break  it  up.  The  large  granular  nucleated  cells  found  in 
ovarian  cysts  are,  according  to  him,  these  lymph  corpuscles.  Nceggerath  considers  that 


FIG.  126. 

SECTION  OF  OVARY  showing  an  epithelial  tube  (at  the  shaded  part  of  the  section).  Lower  down  are 
seen  spaces  of  varying  size,  and  lined  with  a  single  layer  of  epithelium  ;  these  cysts  are  de- 
veloped from  the  epithelial  tubes.  The  connective  tissue  basis  is  shown  only  at  the  shaded  part 
of  section  (De  Sinety).  (*f) 

the  cellular  structures,  which  other  observers  hold  to  be  Pfl  tiger's  ducts,  are  diseased 

View  of       vessels.     De  Sinety  and  Malassez  first  described  certain  epithelial  tubes  (fig.  126)  from 

,          v   which  ovarian  tumours  develop  ;  these  are  not  true  Pfliiger's  ducts,  but  differ  from  them 

Malassez. 


FIG.  127. 
COLLOID  DEGENERATION  of  OVARIAN  STROMA  (Riiidjteisch). 

in  being  hollow  and  having  no  ovum.  They  consider  them  as  Pfluger's  ducts  which  have 
taken  on  a  low  type  of  development.  Colloid  degeneration  of  the  ovarian  stroma 
(fig.  127)  has  been  said  by  Rindfleisch  to  produce  an  ovarian  tumour. 


219 


PATHOLOGY  OF  OVARIAN  TUMOURS. 


The  student  will  therefore  see  that  the  cellular  structures  found 
section  of  ovaries,  although  considered  by  all  as  a  source  of  origin  for   p 
ovarian  cysts,  have  their  nature  disputed.     Noeggerath  believes  them  to 
be  diseased  blood-vessels  ;  Waldeyer,  Spiegelberg,  Schroeder  and  others 
think  them  to  be  Pfliiger's  ducts,  while  Doran  considers  them  to  be 
undeveloped  Graafian  follicles  ;  De  Sinety  and  Malassez  hold  that  they 
are  Pfliiger's  ducts  degraded  in  development  ;  they  are  likely  in  some 
cases  Wolffian  remnants.     The  most  probable  sources  are  undeveloped 
Graafian  follicles  and  relics  of  Wolfiian  bodies. 


VARIETIES    OF    OVARIAN    CYSTS  j    THEIR   NAKED-EYE   AND 
MICROSCOPIC    ANATOMY. 

(1.)  Hydrops  folliculorum  ; 
(2.)  Cystoma  ovarii— 

a.  Cystoma  ovarii  proliferum  glandulare  (arising  in  the 
parenchyma  of  the  ovary), 


Varieties 


F.  T. 


FIG.  128. 

A  SMALL  MULTILOCULAR  OVARIAN  CYST,  slightly  reduced  from  natural  size  (Museum  of  the  Royal 
College  of  Surgeons,  Pathological  Series,  No.  275)  (Doran). 

b.  Cystoma   ovarii   proliferum  papillare  (arising  in   the 

hilum  of  the  ovary), 

c.  Combination  of  a  and  b  ; 
(3.)  Dermoid  cysts ; 

(4.)  Cystoma  malign um. 

Naked-eye  Anatomy. — An  ordinary  multilocular   ovarian   tumour   is  Naked-eye 
best  described  as  made  up  of  two  parts  — the  cyst   and  its   pedicle. Anatomy' 


220  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

The  cyst  is  always  multiple  (fig.  128);  and  the  pedicle  is  usually 
made  up  of  ovarian  ligament,  Fallopian  tube  and  broad  ligament.  In 
the  case  of  the  papillomatous  form  (developing  from  the  hilum)  of 
ovarian  tumour  (fig.  129,  and  PI.  XL  fig.  5),  we  may  still  recognise  the 
ovary,  as  such,  continuous  with  the  tumour;  but  in  the  ordinary 
multilocular  form,  this  cannot  be  done.  In  the  multilocular  form,  on 


F.  T. 


FIG.  129. 

A  LARGE  PAPILLOMATOUS  CYST  springing  from  the  Hilum  of  the  Ovary,  the  greater  part  of  which 
organ  is  not  involved  in  the  morbid  growth.  The  cyst  has  forced  its  way  between  the  layers  of 
the  broad  ligament  as  far  as  the  Fallopian  tube  ;  this  condition  has  been  made  more  clear  by 
removal  of  a  part  of  the  ligament  over  the  tube  and  another  part  over  the  cyst ;  the  correspond- 
ing portion  of  the  wall  of  the  cyst  has  also  been  taken  away  to  expose  the  cavity  (Doran). 

section,  many  cavities  are  found  with  glairy  or  semisolid  contents.  In 
cysts  of  the  hilum  we  have  the  papillomatous  condition  seen  at  fig.  130, 
where  the  papillomata  are  fine  tag-like  projections  and  the  fluid  usually 


FIG.  130. 

SECTION  THROUGH  CYST  WALL,  showing  papillte  covered  with  columnar  epithelium,  and 
sub-epithelial  layer  of  connective  tissue  (RindfleitcK).    (*J2) 

watery.     In   the   multilocular   cysts   we   may   have   papillary   masses 
sprouting    and    coalescing.      Occasionally,    though    very    rarely,    the 


PATHOLOGY  OF  OVARIAN  TUMOURS. 


221 


multilocular  tumour  is  not  formed  of  coalesced  tumours  but  is  grape- 
like  —  Rokitansky's  tumour.  Tait  figures  a  specimen  in  his  work  on 
Diseases  of  the  Ovary  ;  Winckel  and  Olshausen  record  similar  cases. 

Microscopical  Anatomy.  —  Externally  the  cystic  tumour  is  covered  with  Micro- 
cubical  or   flat   cells,   not   with   peritoneum.     Beneath   this   we   have  Anatomy. 
fibrous  tissue  in  lamellse,  while  most  internally  there  is  the  cyst  wall 
with   an   endothelial   or   columnar   cell-lining.     In   the   papillomatous 
tumours,  the  projections  are  covered  with  cylindrical  epithelium,  often 
ciliated,  with  a  core  of  connective  tissue  and  blood-vessels  (fig.  130). 

In  some  cases  of  ruptured  ovarian  cyst  it  has  been  pointed  out  by 
Werth  that,  in  addition  to  the  presence  of  the  gelatinous  cyst-contents 
among  the  abdominal  viscera,  we  may  get  a  special  condition  of  the  peri- 
toneum set  up  to  which  he  gives  the  name  Pseudomyxoma  Peritonei.  In 
one  case  microscopic  examination  of  the  altered  peritoneum  showed 
small-celled  infiltration,  and  extension  of  blood-vessels  as  a  network 
through  the  gelatinous  layer  so  that  the  latter  came  to  lie  in  spaces. 


••   A//;' 
w:;*%$;M 

iS(i''flWw^ 

;-W;5liWfe«*S.S 


FIG.  131. 

ROUND-CELLED  SARCOMA  FROM  A  DERMOID  CYST,  showing  the  transition  from  the  connective  tissue 
of  the  firmer  portion  of  the  tumour  to  the  collection  of  round  cells,  with  a  trace  of  fibrillation 
of  the  intercellular  substance  in  the  softer  portion  of  the  tumour  (Doro.ri). 

Donat  has  also  recorded  a  case  operated  on  by  Sanger,  analogous  to 
those  recorded  by  Werth,  where  recovery  took  place.  He  urges  with 
good  reason  that  the  so-called  "Pseudomyxoma  Peritonei"  is  simply 
peritonitis  set  up  by  the  irritation  of  the  effused  cyst  contents  (Frernd- 
korper  Peritonitis). 

Dermoid  cysts  are  said  to  be  due  to  abnormal  inclusion  of  the  epi- Dermoid 
blast,  i.e.,   are  developmental   in  their   origin.     They  have   an  outer  ys  3> 
fibrous  coat  and  an  inner  one  composed  of  true  skin.     They  may  contain 
hair,  teeth,  bone,  striped  muscle,  nervous  matter,  cholesterine,  and  seba- 
ceous matter.     Doran  draws  attention  to  the  fact  that  dermoid  cysts 
may   contain   malignant   new  growths,   notably   sarcomata  (fig.   131). 
When  teeth  are  present,  their  crowns  have  been  found  to  slope  slightly 
towards  the  median  plane  of  the  body :  in  this  way,  the  side  of  the 
body  from  which  the  tumour  has  arisen  can  be  made  out  (Hollander: 
v.  Olshausen). 


Ovarian 
Fluid. 


222  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

The  Cystoma  malignum  is  a  cystic  tumour  which  has  undergone 
malignant  degeneration.  It  is  noteworthy  that  malignant  disease  often 
develops  after  the  removal  of  an  apparently  simple  tumour,  notably 
after  papillomatous  tumours. 

THE  NATURE  OF  OVARIAN  FLUID. 

Ovarian  fluid  varies  much  in  consistence  and  colour.  It  is  usually 
viscid,  and  may  be  so  thick  as  to  be  almost  gelatinous.  Its  colour  is 
yellowish  or  greenish  ;  and  the  specific  gravity,  when  of  the  more  fluid 
consistence,  varies  from  1010  to  1020.  Chemically,  the  fluid  is  complex. 
The  chemical  composition  has  been  investigated  by  Eichwald,  whose  paper 
may  be  consulted. 

Ovarian  fluid  does  not  give  a  flocculent  precipitate  as  ascitic  fluid  does. 

The  presence  (in  ascitic)  or  absence  (in  ovarian)  of  such  a  precipitate 
can  be  most  easily  determined  by  suspending,  as  Foulis  has  suggested, 
a  soft  cotton  thread  in  a  bottle  containing  the  doubtful  fluid  ;  the  thread 


FIG.  132. 


ed  blood 


SOME  CELLULAR  ELEMENTS  of  OVAKIAN  FLUID.    At  the  upper  right  hand  corner  we  have  red  bio 
corpuscles.     Below  these  lie  the  granular  ovarian  cells,  and  below  them  free  granular  matter. 

At  the  upper  left  hand  corner  is  shown  an  epithelial  cell ;  below  it,  a  pus  cell  after  addition  of 
acetic  acid  ;  and  below  this,  pus  cells  before  addition  of  acetic  acid.  (Drysdale). 

can  then  be  examined  microscopically  for  the  deposit  which  forms  in  its 
interstices. 

The  corpuscular  elements  of  ovarian  fluids  are  various.  There  may 
be  oil  globules,  cholesterine  crystals,  blood  fresh  or  altered,  with  large 
granular  cells. 

S°Bennett  Hu^hes  Bennett  of  Edinburgh  and  Drysdale  of  Philadelphia  have 
and  Drys-  described  a  corpuscle,  seen  at  fig.  132,  as  characteristic  of  ovarian  fluids. 
According  to  Drysdale  it  "is  generally  round,  delicate,  transparent,  and 
contains  a  number  of  granules  but  no  nucleus ; "  its  size  varies  from 
TTHTTT  of  an  incn  to  W?nr  °f  an  inch  in  diameter.  Acetic  acid  added  to 
pus  makes  the  cells  larger  and  brings  nuclei  into  view  ;  while  it  only 
increases  the  transparency  of  the  ovarian  cell  and  makes  its  granules 
more  evident.  Recently,  Garrigues  has  investigated  the  microscopical 


PATHOLOGY  OF  OVARIAN  TUMOURS. 


223 


nature  of  ovarian  fluids  in  an  able  research.  He  believes  Drysdale's  cell 
and  Bennett's  corpuscle  to  be  the  nuclei  of  epithelial  cells  fattily  degener- 
ated, and  that  there  are  no  pathognomonic  ovarian  cells. 

SOLID  OVARIAN  TUMOURS  ;   MALIGNANT  TUMOURS  AND  THE  NATURE  OF 
THE  ASCITIC  FLUID  ASSOCIATED  WITH  THEM. 

Non-malignant  (solid)  tumours  are  rare.     Myoma  of  the  ovary  (fig.  Solid  and 

Malignant 
Tumours. 

F.  ~ 


FIG.  133. 
MYOMA  OF  THE  OVAKY  (Doran). 


133)  has  been  described  by  Doran  ;  and  Cullingworth  has  reported  an 


FIG.  134. 

CANCER  OF  THE  OVARY  (2-inch  and  J-inch  objectives)  (Doran). 

interesting  case  of  fibroma  of  both  ovaries.     A  tubercular  condition  of  the 
ovary  is  found  as  part  of  general  tuberculosis. 


224  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

Malignant  disease  of  the  ovary  is  a  comparatively  frequent  occurrence. 
It  often  complicates  cystic  degeneration,  specially  the  papillary  form  of 
ovarian  cyst.  It  arises  also  independently,  and  may  occur  either  as 
primary  Carcinoma  or  Sarcoma.  Fig.  134  shows  the  character  of  the 
growth  in  a  case  of  scirrhus  of  the  ovary  in  a  girl  aged  fifteen,  described 
by  Thornton  and  Doran. 

Sarcoma  may  occur  both  in  the  spindle-celled  and  alveolar  forms.    The 


FIG.  135. 

SPINDLE-CELLED  SARCOMA  OF  THE  OVARY,  8howing  the  superficial 
and  the  more  central  part  of  the  tumour  (Doran). 

spindle-celled  (fig.  135)  forms  a  transition  from  the  simple  fibro-myo- 
matous  tumour  to  the  alveolar  sarcoma  (fig.  136). 

Foulis'  An  important  feature  is  the  rapid  development  of  ascites,  without  the 

'  existence  of  cardiac,  hepatic,  or  renal  disease  to  explain  it.     Of  great 

importance  are  the  cells  in  the  ascitic  fluid  associated  with  malignant 


FIG.  136. 

ALVEOLAR  SARCOMA  OF  THE  OVARY  (Doran). 

ovarian  disease.  Foulis  has  investigated  this  subject,  and  has  brought 
out  results  of  very  great  value.  Through  his  kindness  we  have  been  able 
to  reproduce  in  Plates  IX.  and  X.  the  cells  he  has  drawn  attention  to ; 
and  he  has  kindly  furnished  us  with  the  following  description. 

"A.  Sprouting  cell  groups  found  in  ascitic  fluid  surrounding  a  large 
cysto-sarcoma  of  the  ovary. 

For  a  history  of  this  case  see  Edin.  Med.  Jour.,  1875,  p.  838. 

In  figures  3,  4,  5,  7,  great  variation  in  form  and  size  of  the  cells  in  each  group 

is  seen.    The  largest  cells  are  generally  seen  at  the  margins  of  the  groups. 
Pig.  9.  Several  large  polynucleated  cells,  evidently  detached  from  cell  groups. 
Fig.  11.  Cells  undergoing  fatty  degeneration. 
Fig.  12.  Blood  corpuscles. 


PLATE  X 


PATHOLOGY  OF  OVARIAN   TUMOURS.  225 

"  B.  Cell  groups  found  in  the  deposit  from  ascitic  fluid  surrounding 
a  large  soft  malignant  tumour  of  the  ovary.  In  many  of 
the  cell-masses,  large  vacuoles  are  seen. 

"  C.  Cell  groups  found  in  the  deposit  from  ascitic  fluid  surrounding 
a  large  flat  or  pancake-shaped  tumour  of  the  omentum.  The 
tumour  was  thought  to  be  ovarian.  In  the  fluid  in  the  pleural 
sacs  exactly  similar  cells  and  cell  groups  were  seen,  and  the 
pleural  surface  of  the  diaphragm  was  studded  over  with  can- 
cerous nodules. 

"  D.  Cell  groups  found  in  ascitic  fluid  in  the  case  of  a  gentleman, 
aged  seventy,  suffering  from  malignant  peritonitis.  In  the 
centre  a  very  large  cell  mass,  with  numerous  vacuoles  in  the 
substance  of  the  protoplasm,  is  seen. 

All  the  cell  groups  and  cells  were  drawn  by  the  aid  of  the  camera 
lucida  under  a  power  of  350  diameters,  with  No.  3  ocular." 

It  is  probable  that  these  liberated  cells  found  in  ascitic  fluid  graft 
themselves  on  the  peritoneum,  and  pass  through  the  diaphragm  into  the 
pleura  and  pericardium.  They  behave  as  we  have  seen  bacteria  do 
(vide  p.  147). 

To  illustrate  the  development  of  the  normal  ovary  and  of  the  Graafian 
follicles,  we  have  added  the  following  figures  from  Foulis'  paper  on  this 
subject. 

Plate  X. — "  E,  Section  through  ovary  and  Wolffian  body  of  a  foetal 
lamb. 

a  stalk  of  ovary,  STR  stroma,  MD  duct  of  Mtiller,  e  epithelium 
of  peritoneum,  g  germ  epithelium,  y  deepest  part  of  the  paren- 
chymatous  zone  of  the  ovary. 

F.  Connective  tissue  sprouting  out  and  surrounding  the 
germ  epithelium." 

PAROVARIAN  CYSTS. 

These  tumours  are  developed  from  the  parovarium,  have  a  separable  Parovarian 
peritoneal  covering,  are  thin-walled,  and  contain  a  watery  fluid  which  is   ys  s< 
little  more  than  a  mere  solution  of  salt.    They  may  contain  papillomatous 
growths,  however,  owing  to  their  Wolffian  origin — an  argument  for  their 
being  always  removed  by  abdominal  section.     Small  parovarian  tumours 
are  common,  but  they  may  also  be  of  very  large  size.     They  are  seldom 
lined  by  ciliated  epithelium,  but  usually  by  cubical  or  squamous  cells,  the 
flattening  being,  according  to  Spiegelberg,  due  to  pressure  of  contents. 

It  must  be  remembered  of  course  that  all  cysts  of  the  broad  ligament 
are  not  parovarian  in  their  origin.     Parovarian  cysts  are  in  the  site  of 
the  parovarium,  with  the  ampullary  portion  of  the  tube  and  the  ovarian 
fimbria  stretched  and  the  ovary  intact. 
p 


226  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

OTHER   BROAD    LIO-AMENT   CYSTS 
(PAROVARIAL   CYSTS). 

Parovarial  By  these  we  mean  cysts  developed  in  the  broad  ligament  but  not  from 
the  ovary  or  parovarium.  They  are  however  identical  in  origin  with 
Parovarian  cysts,  as  they  arise  from  Wolffian  relics ;  further,  they  may 
be  papillomatous. 

The  direction  of  development  of  these  tumours  is  of  great  practical 
interest  as  they  may  spread  within  the  folds  of  the  ligament  towards  the 
side  of  the  pelvis,  towards  the  uterus,  or  down  in  the  direction  of  Douglas' 
pouch.  This  renders  their  removal  troublesome  as  they  have  then  to  be 
enucleated,  owing  to  the  absence  of  a  pedicle  (v.  Plate  XL). 

These  cysts  may  rupture  and  cause  infective  papillomatous  growths  of 
peritoneum  and  ovary. 


F.  T. 


B.L.C. 


FIG.  137. 

A  SIMPLE  BROAD  LIGAMENT  CYST  (Damn). 
Or.  Ovary  split  open  ;  F.  T.  Fallopian  tube ;  B.L.C.  Broad  ligament  cyst. 

Plate  XI.  from  Coblenz  will  be  helpful  to  the  student  in  enabling  him 
to  understand  the  genesis  of  ovarian  tumours,  and  will  also  show  him 
the  value  of  a  knowledge  of  development  in  clearing  up  the  origin  of 
disease. 

Fig.  1  shows  diagrammatically  the  development  of  the  urinary  and 
generative  organs  in  the  human  foetus — female  organs  (chiefly  developed 
from  the  ducts  of  Muller  while  the  Wolffian  bodies  are  rudimentary) 
shown  to  the  right  of  the  line  m,  and  male  organs  (chiefly  developed 
from  the  Wolffian  bodies  while  the  ducts  of  Muller  are  rudimentary)  to 
the  left.  The  rudimentary  organs  are  coloured  blue  in  the  figure.  On 
both  sides,  we  have  nn  supra-renal  capsule,  n  kidney,  u  ureter,  v  bladder, 
ua  urethra ;  to  the  right  (female  organs)  are  0  ovary,  po  parovarium, 


PLATE  XI. 


DIAGRAM  OF  MODE  OF  ORIGIN  AND  GROWTH  OF  MULTILOCULAR  AND 
PAPILLOMATOUS  OVARIAN  TUMOURS  (COBLENZ). 


PATHOLOGY   OF   OVARIAN  TUMOURS.  227 

wb  part  of  Wolffian  body  not  forming  parovarium,  gc  Wolffian  duct 
persisting  in  Gartner's  canal,  of  fimbriated  end  of  tube,  ft  Fallopian 
tube,  ut  uterus,  vg  vagina,  ur  urachus ;  to  the  left  (male  organs)  are 
T  testis,  ep  epididymis,  vd  vas  deferens,  md  duct  of  Miiller  rudimentary 
down  to  vp  vesicula  prostatica. 

Fig.  2  shows  the  fully-developed  generative  organs  in  the  female  :  on 
the  left,  the  organs  found  in  the  normally  developed  female  are  given ; 
while,  on  the  right,  the  coloured  portion  shows  the  rudimentary  struc- 
tures from  which  there  may  be  pathological  development.  On  the  left, 
the  broad  ligament  is  supposed  to  have  been  removed  ;  on  the  right,  the 
organs  are  shown  in  coronal  section  (^  nat.  size) ;  ota  ostium  tubse 
abdominale,  km  hydatis  Morgagni,  fo  ovarian  fimbria,  0  ovary,  lo  ovarian 
ligament,  po  parovarium,  Ir  round  ligament,  vg  vagina,  wv  upper  wall 
of  vestibule,  cc  corpus  cavernosum  clitoridis,  u  ureter,  I  labium  minus, 
Im  labium  majus;  wb  Wolffian  body  in  its  special  separate  parts  as 
follows : — 

Segment  I.  parovarium,  II.  III.  IV.  normally  obliterated  parts  of 
Wolffian  body  and  duct.  From  II.  we  may  get  cysts  of  broad  ligament 
developing  as  well  as  papillomatous  ovarian  ones.  From  the  duct  (III. 
and  IV.),  we  may  get  cysts  of  cervix  uteri  and  vagina. 

Fig.  3  shows  a  section  (in  line  ss  Fig.  2)  of  broad  ligament,  Fal- 
lopian tube,  and  ovary.  The  blue  line  pp  is  the  peritoneum,  u  being 
posterior  layer  of  broad  ligament  ;  the  red  one,  the  germ  epithelium 
of  ovary  ;  t  tube,  ov  ovary,  Ir  round  ligament. 

Fig.  4  shows  development  of  ordinary  multilocular  tumour  :  C  cystic 
and  o  v  solid  parts  of  tumour ;  a  a  line  of  section  when  tumour  is  removed  ; 
other  letters  as  before. 

Fig.  5  shows  a  tumour  which  is  multilocular  and  papillomatous,  the 
latter  feature  caused  by  Wolffian  remains  at  hilum  of  ovary. 

Fig.  6  shows  papillomatous  tumour  of  the  parovarium  developing  in 
broad  ligament,  the  ovary  being  intact. 

Fig.  7  shows  papillomatous  cyst  extending  within  the  layers  of  broad 
ligament  developed  from  remains  of  Wolffian  body  and  pushing  up 
posterior  layer  of  broad  ligament  (cf.  Fig.  3u). 

The  student  will  see  by  comparing  Figs.  3,  4,  5,  6,  and  7,  how 
glandular  and  papillomatous  cysts  alter  the  relations  of  structures  in 
the  broad  ligament.  He  will  also  understand  the  formation  of  the 
pedicle  (v.  figs.  4,  5,  and  6),  as  well  as  the  necessity  for  enucleation  in 
such  a  case  as  Fig.  7. 

RELATION  OF  EVOLUTION  TO  THE  PATHOLOGY  OF  OVARIAN  TUMOURS. 

As  we  have  seen,  the  undeveloped  Graafian  follicles  are  the  most 
probable  source  of  the  multilocular  ovarian  tumour.  From  the  remains 
of  the  Wolffian  body  known  as  the  Parovarium  the  parovarian  tumour 


228  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

develops  :  while  from  the  less  constant  remains  at  the  ovarian  hilum 
and  near  the  uterus,  the  infective  papilloma  arise. 

It  is  remarkable  that  in  the  ovary  of  woman  we  should  have  not  only 
so  many  thousands  of  unnecessary  Graafian  follicles  formed,  but  that 
at  an  early  period  of  intrauterine  existence  there  should  be  in  the  foetus 
structures  from  which  both  ovaries  and  testes  are  developed,  and  that, 
in  the  Wolffian  relics  already  mentioned,  the  adult  woman  should  have 
traces  of  what  in  the  other  sex  developes  into  the  male  organs.  At 
present,  we  know  of  no  explanation  of  these  facts  unless  on  the  evolution 
hypothesis.  Whether  this  explanation  will  hold  good  it  is  impossible 
to  say,  but  at  present  it  appears  that  to  structures  which  in  her  are 
rudimentary  and  functionless  woman  is  mainly  indebted  for  the  serious 
risks  of  ovarian  cysts,  simple  and  malignant. 


CHAPTER  XXIII. 

DIAGNOSIS  OF  OVARIAN  TUMOURS. 

LITERA TURK 

Atlee,  W.  L. — The  General  and  Differential  Diagnosis  of  Ovarian  Tumours  :  Lippincott 
and  Co.,  Philadelphia,  1873.  On  Sarcoma  of  the  Ovaries  :  Am.  Gyn.  Tr.,  Vol.  II. 
Barnes — Diseases  of  "Women,  p.  400  :  London,  1878.  Brown,  J.  Baker — Surgical 
Diseases  of  Women  :  London,  1866.  Duncan,  J.  Matthews — Diseases  of  Women : 
London,  Churchill,  1886.  Hicks,  Braxton — Further  Remarks  on  the  Use  of 
Intermittent  Contractions  of  the  Pregnant  Uterus  as  a  means  of  Diagnosis  :  Lond. 
Inter.  Congress  Tr.,  1882.  Also  Tr.  of  Lond.  Obst.  Soc.,  Vol.  XIII.,  and  Proc.  of 
Royal  Soc.  of  Lond.,  1878.  Jastrebow — On  a  point  in  the  Diagnosis  of  Ovarian 
Tumours:  Lond.  Inter.  Congress  Tr.,  1882.  Olshausen — Die  Krankheiten  der 
Ovarien :  Billroth's  Handbuch,  Stuttgart,  1877.  Ritchie,  C.  G. — Contributions  to 
Ovarian  Physiology  and  Pathology  :  Churchhill,  London,  1865.  Schroedei — Hand- 
buch der  Krankheiten  der  weiblichen  Geschlechtsorgane :  Leipzig,  1879.  Tait, 
Lawson — Diseases  of  the  Ovary ;  Cornish,  Birmingham,  1883.  Wetts,  Sir  T.  Spencer 
— Ovarian  and  Uterine  Tumours:  London,  1882.  Williams,  John— Ovarian  Turn  ours: 
Reynold's  System  of  Medicine,  Vol.  V.  Lectures  on  the  Diagnosis  and  Surgical 
Treatment  of  Abdominal  Tumours  :  Br.  Med.  Jour.,  1878. 

FOR  convenience  we  take  up  the  diagnosis  and  differential  diagnosis  of 
ovarian  tumours  under  three  heads  : — 

A.  When  small  (pelvic  in  position); 

B.  When  large,  multilocular,  and  pediculated  (chiefly  abdo- 

minal in  position) ; 

C.  When  large  and  extraperitoneal  (often  papillomatous). 

A.    WHEN    SMALL    (PELVIC    IN    POSITION). 

These   may   be   either   (a.)  Lateral   to   uterus,  or  (b.)  Posterior  to 
uterus. 

(a.)  Pelvic  ovarian  tumours  lateral  to  Uterus. 

1.  Symptoms. — These  are  chiefly  those  of  pressure  and  bearing-down,  Diagnosis 
and  have  no  diagnostic  value.     There  is  no  menorrhagia.  Tumours'11 

2.  Physical  signs. — Palpation  and  percussion   give  evidence  of  the  when 
presence  of  a  tumour  only  when   it  projects  much  above  the  brim. 
Auscultation  gives  negative  results.     On  vaginal  examination,  the  cervix  Uterus, 
is  found  displaced  to  the  side  opposite  to  that  where  the  tumour  is. 
Through  the  fornix  a  tense,  rounded,  fluctuating  mass  is  felt  projecting 
downwards.     Bimanually  the  uterus  is  felt  not  enlarged,  but  is  displaced 

to  the  one  side  and  is  distinct  from  the  tumour,  which  can  be  mapped 


230  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

out  between  the  hands.  Usually  the  uterus  and  tumour  are  not  very 
movable,  owing  to  the  limited  space  of  the  pelvic  cavity.  When  the 
tumour  is  tapped,  ovarian  fluid  is  got. 

3.  Differential  diagnosis. — When  lateral  to  the  uterus,  they  require  to 
be  differentiated  from  the  following  : — 
(1.)  Pelvic  cellulitis ; 

(2.)  Pelvic  peritonitis  (encysted  serous  effusions) ; 
(3.)  Parovarian  cysts ; 
(4.)  Hydrosalpinx,  Pyosalpinx  ; 
(5.)  Fallopian- tube  gestation ; 
(6.)  Fibroid  and  fibro-cystic  tumours  of  uterus  ; 
(7.)  Blood  effusion ; 
(8.)  Solid  ovarian  tumours. 

(1.)  Pelvic  cellulitis. — With  this  we  have  inflammatory  history  and 
probable  cause  (as  abortion  or  labour)  to  guide  us.  When  the  cellulitis 
has  gone  on  to  suppuration,  there  will  be  rigors  and  other  indications  of 
suppuration.  Cellulitic  deposits,  unless  when  in  the  broad  ligament, 
are  always  fixed ;  are  firm  when  not  purulent,  and  even  when  purulent 
do  not  give  very  distinct  fluctuation. 

(2.)  Pelvic  peritonitis. — This  will  not  cause  the  fornix  to  bulge 
downwards,  and  the  history  will  help  us.  Tapping  gives  serum,  and 
not  ovarian  fluid.  When  an  ovarian  tumour  is  fixed  by  peritonitic 
adhesions,  it  will  be  almost  impossible  to  diagnose  it  from  encysted 
pelvic  peritonitic  effusion  except  by  examination  of  the  fluid. 

(3.)  Parovarian  cysts  are  not  so  rounded  and  have  very  distinct 
fluctuation ;  their  secretion  is  usually  simple  salt  and  water. 

(4.)  Hydrosalpinx  and  pyosalpinx  are  high  in  pelvis,  tortuous,  elon- 
gated from  side  to  side. 

(5.)  Extra-uterine  gestation. — The  symptoms  and  signs  of  pregnancy 
with  a  tumour  beside  the  uterus  corresponding  to  the  period  of  amenor- 
rhoea  (sometimes  masked  however  by  irregular  haemorrhages  from  the 
uterus)  point  to  extra-uterine  gestation. 

(6.)  Fibroid  and  Jibro-cystic  tumours  of  uterus  (v.  Section  V.). 
(7.)  Blood  effusion  in  the  broad  ligaments  is  more  difficult  to  diagnose 
during  life,  but  sudden  onset  with  history  of  fainting  and  pallor  are 
found  (v.  Chap.  XVI.). 

(8.)  Solid  ovarian  tumours  are  rare.  When  malignant,  there  are  often 
nodules  in  the  fornices  and  ascitic  fluid  which  shows  the  cells  shown  at 
Plates  IX.  and  X. 

Diagnosis 

Ovarian0  (k)  Pd™  Ovarian  Tumours  posterior  to  Uterus. 

Tumours  -i      c-         t  mi 

when  *'•  symptoms.  —  ine  most  noticed  ones  are  associated  with  urination; 

posterior1   ^ere  may  be  either  retention  or  constant  desire  to  micturate.     There 
to  Uterus,  is  no  menorrhagia. 


DIAGNOSIS  OF  OVARIAN  TUMOURS.  231 

2.  Physical  signs. — Palpation,  auscultation,  and  percussion  give  the 
same  result  as  when  the  tumour  is  lateral.  On  bimanual  examination, 
the  uterus  is  felt  markedly  displaced  to  the  front  but  is  not  enlarged  ; 
and  bulging  downwards  behind  the  cervix,  the  round  globular  cystic 
ovary  can  be  grasped.  Tapping  gives  ovarian  fluid. 

Differential  diagnosis. — When  posterior  to  the  uterus,  they  require  to 
be  differentiated  from  the  following  conditions. 

(1.)  Encysted  serous  peritonitic  effusion, 

(2.)  Retro-uterine  hsematocele, 

(3.)  Fibroid  and  fibro-cystic  tumours  of  the  uterus, 

(4.)  Retroverted  gravid  uterus  and  extra-uterine  fetation, 

(5.)  Parovarian  cysts. 

(1.)  Peritonitic  effusion  has  an  inflammatory  history;  it  is  not  so 
rounded  nor  so  well  defined  above.  The  fluid  is  serous. 

(2.)  Retro-uterine  hcematocele  has,  after  the  blood  has  coagulated,  a 
hard  feeling  and  is  more  expanded  transversely.  There  is  a  history  of 
sudden  onset,  menorrhagia,  and  subsequent  inflammatory  symptoms. 

(3.)  Fibroid  and  fibro-cystic  tumour  of  the  uterus  (v.  Section  V.). 

(4.)  Retroverted  gravid  uterus  and  extra-uterine  gestation. — In  both 
of  these  there  will  be  the  signs  and  symptoms  of  pregnancy;  the 
amenorrhoea  in  the  latter  case  may  be  masked  by  haemorrhages  from 
the  uterus. 

(5.)  Parovarian  cysts. — The  character  of  the  fluid  is  our  only  certain 
guide. 

It  should  be  specially  noted  that  these  pelvic  ovarian  tumours  are  apt 
to  cause  pelvic  inflammation,  and  thus  render  the  exact  diagnosis,  unless 
aided  by  tapping,  very  difficult. 

B.    DIAGNOSIS    OF    OVARIAN   TUMOURS    WHEN    LARGE,    MULTILOCULAR,    AND 
PEDICULATED    (CHIEFLY    ABDOMINAL    IN    POSITION). 

1.  Symptoms. — These   are   chiefly   due   to   its   bulk.     The   patient's  Diagnosis 
notice  is  attracted  to  the  fact  that  she  is  getting  rapidly  stout. 

2.  Physical   signs. — When    the  patient   lies   on    her   back   and    the 
abdominal  surface  is  exposed,  the  following  points  can  be  noted. 

On  inspection  the  abdomen  is  seen  to  be  greatly  distended.  The  dis 
tention  may  be  uniform,  but  is  often  more  or  less  markedly  lateral. 
The  distance  from  the  anterior  superior  spinous  process  to  the  umbilicus 
is  greater  on  one  side  than  the  other.  The  superficial  abdominal  veins 
may  be  dilated,  and  lineae  albicantes  are  sometimes  present. 

On  palpation,  the  distention  is  felt  to  be  due  to  an  encysted  collection 
of  fluid.  A  mass  is  felt  in  the  abdominal  cavity  which  is  like  a  sac  filled 
with  fluid.  Fluctuation  is  got  by  placing  one  hand  at  a  special  part  and 
tapping  at  an  opposite  point  with  the  fingers  of  the  other  hand.  How- 


232  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES, 

ever  long  the  tumour  be  manipulated,  there  is  never  felt  any  muscular 
contraction  of  the  cyst  wall. 

On  percussion  when  the  patient  lies  dorsal,  a  dull  note  is  obtained  over 
the  tumour  (fig.  138) ;  but  at  the  flank  where  the  tumour  does  not  bulge, 
it  is  clear  and  tympanitic,  since  the  intestines  are  there.  When  the 
patient  turns  on  her  side,  with  this  flank  uppermost,  the  dulness  and 
tympanitic  note  do  not  change  in  position.  This  sign  shows  we  have 
to  deal  with  an  encysted  collection  of  fluid. 

Auscultation  gives  entirely  negative  results.  No  sound  is  heard  unless 
that  of  friction  over  a  localised  peritonitis. 

On  vaginal  examination,  the  uterus  is  felt  displaced  to  one  or  other 


FIG.  138. 
The  shaded  portion  shows  the  dull  area :  left  figure,  ovarian  tumour  ;  right  figure,  ascites  (Barnes). 

side,  or  very  much  to  the  front.  It  is  rarely  retroverted,  and — unless 
impregnated — is  not  enlarged.  The  tumour  does  not  usually  bulge 
down  into  the  fornices,  but  may  be  made  out  bimanually. 

In  order  to  ascertain  how  the  pedicle  lies,  we  have  to  make  the 
examination  per  rectum.  The  tumour  is  drawn  upwards  in  the 
abdominal  cavity  by  an  assistant.  We  now  lay  hold  of  the  cervix 
with  a  volsella,  pass  the  index  finger  of  the  right  hand  into  the  rectum, 
make  traction  on  the  cervix  till  the  fundus  is  brought  within  reach  of 
the  rectal  finger.  AVe  recognise  a  tense  band  passing  from  one  angle  of 
the  fundus,  and  the  enlarged  ovarian  artery  may  be  felt  pulsating  in  it. 
AVe  now  examine  for  the  ovary  of  the  opposite  side,  to  ascertain  if  it 
is  normal  in  size.  The  possibility  of  both  ovaries  being  cystic  (which 
would  produce  a  pedicle  on  each  side),  should  not  be  forgotten,  though 


DIAGNOSIS  OF  OVARIAN  TUMOURS.  233 

this  is  comparatively  rare.  The  examination  with  the  volsella  is  made 
easier  by  placing  the  patient  in  the  genupectoral  posture ;  the  weight  of 
the  tumour  makes  it  gravitate  into  the  abdomen,  and  renders  the 
pedicle  tense ;  it  is  also  easier  to  make  the  rectal  examination  in  this 
position. 

3.   Differential  Diagnosis.  Differen- 

They  must  be  diagnosed  from  the  following  conditions  : —  nosis     8 

(1.)  Pregnancy  and  Hydramnios, 
(2.)  Fibroma  uteri, 
(3.)  Ascitic  fluid, 

(4.)  Fibrocystic  tumours  of  the  uterus, 
(5.)  Parovarian  tumours, 
(6.)  Encysted  dropsy, 

(7.)  Thickened  omentum  enclosing  intestines  by  adhesions, 
(8.)  Omental  tumours, 
(9.)  Renal  tumours, 
(10.)  Hydatid  of  liver, 
(11.)  Pseudocyesis, 
(12.)  Distended  bladder. 

In  examining  a  case  of  abdominal  tumour,  the  practitioner  first  makes 
his  examination  systematically — in  every  case  what  is  called  the  routine 
examination,  noting  what  he  observes.  By  this  means  he  may  get  facts 
enough  to  warrant  his  drawing  a  positive  conclusion  as  to  its  nature. 
This,  however,  is  not  always  the  case,  and  he  has  then  to  use  diagnosis 
by  exclusion :  it  must  be  one  of  a  certain  fixed  number  of  things, 
and  the  possibilities  are  excluded  one  by  one  till  a  definite  diagnosis 
is  reached.  When  examination  is  unsatisfactory,  it  should  be  repeated 
under  chloroform. 

We  have  stated  above  that  ovarian  tumours  require  to  be  diagnosed 
from  twelve  conditions.  On  each  of  these  we  make  some  brief  remarks. 
(1.)  Pregnancy. — At  the  period  of  pregnancy  when  the  uterus  is  so 
enlarged  as  to  be  above  the  pelvic  brim,  certain  conditions  are  present. 
These  are  suppression  of  menstruation  for  a  given  period,  and  size  of  the 
uterus  corresponding  to  this  ;  mammaiy  signs  ;  linese  albicantes,  and  pig- 
mentation. On  palpation,  we  feel  a  tumour  without  distinct  fluctuation 
and  having  intermittent  contractions;  the  foetus  can  be  palpated  out. 
The  foetal  heart  (after  the  fourth  month)  and  the  uterine  souffle  are 
heard.  The  vagina  is  dark  in  colour,  the  mucous  secretion  increased, 
and  the  cervix  soft. 

We  need  hardly  say  that  palpation,  the  foetal  heart-sounds,  bruit 
and  vaginal  changes  mark  out  the  pregnancy  unmistakably.  These 
points  may  seem  too  simple  to  require  mention,  but  cases  have  been 
recorded  where  the  pregnant  uterus  has  been  tapped  for  an  ovarian 
cyst. 


234  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

Hydramnios  may  simulate  an  ovarian  cyst.  The  amenorrhcea  will 
help,  aud  especially  the  occurrence  of  intermittent  contractions  as  Braxton 
Hicks  has  specially  pointed  out.  In  one  of  his  recorded  cases,  the 
tumour  was  the  size  of  a  seven  months'  uterus  with  distinct  fluctuation, 
and  there  was  amenorrhoea  for  five  months.  Palpation  gave  the  uterine 
hardening.  Previous  to  this  it  had  been  tapped  as  a  cystic  ovarian 
tumour. 

(2.)  Fibroma  uteri  (v.  Section  V.). 

(3.)  Ascitic  fluid. — When  the  patient  lies  on  the  back,  percussion 
gives  a  tympanitic  note  at  the  umbilicus  and  a  dull  one  at  the  flanks 
(fig.  138) ;  when  on  the  left  side,  the  note  is  dull  on  that  side  and  clear 
over  the  right ;  when  on  the  right,  it  is  dull  on  that  side  and  tympanitic 
on  the  left;  when  she  sits  up,  the  upper  limit  of  the  dulness  is  curved 
with  the  convexity  downwards. 

The  reason  of  this  is  evident.  The  intestines  float  on  the  fluid  at  its 
highest  point,  and  give  the  tympanitic  note  accordingly  (fig.  138). 

(4.)  Fibrocystic  tumours  of  the  uterus  are  difficult  to  diagnose.  The 
following  points  should  be  noted.  Fluctuation  is  only  partial  and  the 
consistence  is  variable  ;  the  rate  of  growth  is  slower ;  and  the  fluid  drawn 
off  coagulates  spontaneously  (Atlee).  It  is  often  difficult  to  distinguish 
these  from  ovarian  tumours,  and  the  best  operators  have  sometimes  failed 
to  do  so  (v.  Section  V.). 

(5.)  Parovarian  tumours  have  very  well-marked  fluctuation,  have  their 
characteristic  fluid,  and  when  once  tapped  do  not  usually  refill  as  they 
are  often  retention  cysts. 

(6.),  (7.),  and  (8.).  In  many  cases  we  can  make  out  that  the  tumour 
does  not  pass  down  into  the  pelvis  and  is  not  connected  with  the  uterus. 
Sometimes  the  case  is  obscure,  and  abdominal  incision  alone  clears 
matters  up. 

(9.)  Renal  tumours  grow  downwards  and  inwards,  have  all  their  edges 
rounded,  and  do  not  as  a  rule  project  posteriorly.  When  right-sided,  the 
colon  lies  between  them  and  the  liver.  Their  fluid  contains  urea. 

(10.)  The  hydatid  is  connected  with  the  liver  and  contains  hooklets. 

(11.)  In  Pseudocyesis,  the  percussion  note  is  tympanitic  and  the 
swelling  disappears  under  chloroform. 

(12.)  The  distended  bladder  is  of  course  emptied  by  the  catheter. 

WHEN    LARGE   AND    EXTRAPERITONEAL    (OFTEN    PAPILLOMATOUs). 

In  this  class  the  tumour  is  not  pediculated,  and  in  its  extraperitoneal 
burrowing  growth  pushes  aside  uterus,  bladder,  or  large  intestines,  so 
that  extreme  displacement  of  these  may  take  place  (v.  fig.  7,  PI.  XL). 
It  is  therefore  of  importance  in  the  diagnosis  of  large  abdominal  cysts  to 
ascertain  the  position  of  the  uterus,  and  also  the  percussion  note  so  as 
to  make  out  if  large  intestine  is  displaced.  When  these  tumours 


DIAGNOSIS  OF  OVARIAN  TUMOURS.  235 

develop  laterally,  the  displacement  of  the  uterus  is  an  aid  to  diagnosis; 
when  posterior  to  the  uterus,  however,  their  diagnosis  is  less  easy,  as 
they  may  only  slightly  displace  the  uterus.  They  usually  then  bulge 
well  down  into  the  pelvis,  lying  below  the  peritoneal  level.  Their 
existence  should  therefore  be  suspected — 

(1.)  If  uterus  or  bladder  is  displaced  markedly; 
(2.)  When  over  a  cyst  of  size  sufficient  to  displace  the  small 
intestine,  we  get  a  tympanitic  note.     This  indicates  dis- 
placement  of  large  intestine,  which   can  only  be  done 
by  an  extraperitoneal  cyst. 

DIAGNOSIS   OF   ADHESIONS. 

When   pelvic,    the   fixation  of  the  tumour  they  cause  can   be  felt.  Diagnosis 
Adhesions  are  often  the  result  of  tapping;  they  may  also  arise  fromsions- 
mere  pressure.     Careful  inquiry  should  always  be  made  as  to  the  his- 
tory of  inflammatory  attacks.     On  palpating  the  tumour,  one  can  often 
feel  friction.     On  making  the  patient  take  a  deep  breath,  it  should  be 
noted  whether  the  abdominal  walls  move  over  the  surface  of  the  tumour. 
Much  less  importance  is  attached  nowadays  to  the  existence  of  ab- 
dominal adhesions.     When  pelvic,  especially  if  to  the  bladder  or  deep 
in  the  pouch  of  Douglas,  they  are  more  serious. 

CO-EXISTENCE    OP   PREGNANCY   AND   OVARIAN   TUMOUR. 

It   should  be   kept  in   mind  that   pregnancy  may  co-exist   with  anCo-exist- 
ovarian  tumour,  giving  its  own  special  symptoms  and  physical  signs  i 
addition. 


CHAPTER  XXIV. 

OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS. 

LITERA  TDRE. 

Atlee—The  General  and  Differential  Diagnosis  of  Ovarian  Tumours :  Philadelphia,  1873. 
Bantock— First  Series  of  Twenty-five  Cases  of  Completed  Ovariotomy  :  Brit.  Med. 
Jour.,  1879,  p.  766.  Specimen  illustrating  the  changes  in  the  Pedicle  of  an  Ovarian 
Cyst  when  treated  by  Ligature  :  Tr.  Lond.  Obst.  Soc.,  XIV.,  1872.  Early  Operative 
Treatment  of  Ovarian  Cysts  :  Lond.  1882.  Cheyne,  Watson — Antiseptic  Surgery  : 
Smith,  Elder,  &  Co.,  London,  1882.  Cfiiara— Accidental  Puncture  of  Pregnant 
Uterus:  Annali  di  Ostetricia,  etc.,  1885,  412  and  453.  Goodell,  Wm.—  Article 
"Ovariotomy  :  "  in  Vol.  II.,  American  System  of  Gynecology  and  Obstetrics  (edited 
by  Mann).  See  also  Amer.  Jour,  of  Obst.,  Jan.  1888.  Hegar  und  Kaltenlach — Die 
operative  Gynakologie  :  Stuttgart,  1881,  S.  201.  Lee,  G.  C.— Accidental  Puncture 
of  the  Pregnant  Uterus  :  Amer.  Jour.  Obstet. ,  1885,  190.  Lister — Address  on  the 
Treatment  of  Wounds  :  Lancet,  Nov.  19  and  26,  1881.  M ahomed—  Lancet,  1879. 
Miner— Ovariotomy  by  Enucleation  :  Philad.  Intern.  Cong.  Tr.,  1877.  Munde, 
P.  F. — The  Value  of  Electrolysis  in  the  Treatment  of  Ovarian  Tumours  :  Am.  Gyn. 
Tr.,  Vol.  II.,  p.  348.  Semeleder— Twenty  Cases  of  Ovarian  Cysts  treated  by 
Electrolysis :  Am.  Jour,  of  Obst.,  XV.,  515.  Sims,  J.  M. — Thomas  Keith  and 
Ovariotomy  :  Am.  Jour,  of  Obst.,  April  1880.  Tail,  Lawson — On  Axial  Rotation  of 
Ovarian  Tumours  leading  to  their  Strangulation  and  Gangrene  :  London  Obst.  Tr., 
Vol.  .XXII.,  p.  86.  The  Antiseptic  Theory  tested  in  Ovariotomy  :  Lond.  Roy.  Med. 
and  Chir.  Tr.,  Vol.  LXIIL,  p.  161.  Recent  Advances  in  Abdominal  Surgery  : 
London  Intern.  Cong.  Tr.,  1882.  Diseases  of  the  Ovary:  Birmingham,  1883. 
Thornton,  J.  K. — The  Silk  Ligature  as  a  means  of  securing  the  Ovarian  Pedicle  : 
Brit.  Med.  Jour.,  1878,  p.  125.  Also,  "Rotation  of  Ovarian  Tumours  ;  its  Etiology, 
Pathology,  Diagnosis,  and  Treatment :  "  Inter.  Jour,  of  Med.  Sc.,  Vol.  XCVI.,  p.  357. 
Wells,  Sir  T.  S. — Ovarian  and  Uterine  Tumours  :  Lond.  1882.  Recent  Advances  in 
the  Surgical  Treatment  of  Intraperitoneal  Wounds  :  London  Intern.  Cong.  Tr., 
1882.  Additional  Cases  of  Ovariotomy  performed  during  Pregnancy  :  London  Obst. 
Tr.,  Vol.  XIX.,  p.  184.  See  also  Index  of  Recent  Gynecological  Literature  in  the 
Appendix. 

Treatment  REMOVAL  of  the  ovarian  tumour,  or  Ovariotomy,  is  the  treatment  now 
Tumours,   practised.       Other   methods   have,  however,  been   employed  ;   a   brief 
resumd  of  these  will  be  useful  to  the  student. 

Exploded        These  methods  have  been  tapping,  tapping  and  injection  of  the  cyst  with   iodine, 
Methods,     electrolysis,  drainage  into  the  peritoneal  cavity  or  through  the  vagina. 

Tapping  is  not  a  method  of  treatment  followed  by  cure,  and  should  be  used  only  when 
it  is  absolutely  necessary  to  obtain  fluid  for  diagnosis.  It  may  cure  parovarian  cysts,  but 
it  is  best  to  remove  them  by  abdominal  section.  Ovarian  cysts  are  not  retention  cysts 
but  have  a  proliferating  lining  membrane,  for  which  reason  tapping  does  not  cure  them. 
An  additional  reason  against  tapping  is  that  it  is  a  procedure  by  no  means  free  from 
danger,  even  to  life.  By  oozing  of  the  fluid  through  the  puncture,  adhesions  are  set  up  : 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    237 

in  some  cases,  septic  peritonitis  has  proved  fatal.  Tapping,  further,  is  only  palliative 
and  must  be  followed  by  ovariotomy. 

Method  of  Tapping. — See  that  the  bladder  is  empty.  With  the  patient  lying  on  her 
back  make  an  incision  through  skin  and  fat  for  about  an  inch,  and  midway  between 
umbilicus  and  pubes.  Then  plunge  in  the  trocar  seen  at  fig.  140.  To  the  side-tube  a 
long  piece  of  tubing  is  attached,  which  dips  under  water.  While  the  fluid  is  flowing,  the 
patient  lies  on  her  side.  No  bandage  is  necessary.  Care  should  be  taken  to  prevent 
regurgitation  of  air,  and  a  suitable  dressing  should  be  applied  to  the  wound  (vide  under 
Ovariotomy). 

Tapping  and  injection  of  the  cyst  with  iodine  is  a  procedure  not  now  practised,  owing  to 
the  risks  and  uncertainty  attending  it. 

Electrolysis  was  at  one  time  advocated  as  a  means  of  cure.  Its  pretensions  to  this  are 
unfounded,  and  few  now  practise  it.  Its  use  has  been  carefully  considered  by  Munde  of 
New  York,  and  Semeleder,  city  of  Mexico,  in  the  articles  cited,  which  may  be  consulted 
for  details  and  information. 

Drainage  into  the  peritoneal  cavity,  or  through  the  vagina. — The  former  is  dangerous, 
and  the  latter  is  practised  only  where  the  cyst  is  immovably  fixed  by  adhesions. 

One  fact  must  be  finally  noted.  Cases  of  cure  of  ovarian  cysts  by  tapping,  drainage, 
or  electrolysis,  are  sometimes  recorded.  These  cysts  have  probably  not  been  ovarian 
but  cysts  of  the  broad  ligament — parovarian.  Mere  tapping  often  .cures  the  latter. 
Electrolysis  does  the  same.  Electricity  has  nothing  to  do  with  it,  the  puncture  of  the 
needle  is  enough. 

OVARIOTOMY. 

This  used  to  be  performed  either  by  vaginal  or  abdominal  incision. 
The  former  is  now  never  employed. 

VAGINAL   METHOD. 

This  was  practised  when  the  tumour  was  pelvic  and  small.     Thomas  of  New  York,  Vaginal 
Goodell  of  Philadelphia,  Gilmore,   Hamilton,  and  others  have  recorded  cases.     TheOvari- 
following  was  the  plan  of  procedure.  otomy. 

Chloroform  or  etherize  the  patient.  Place  her  semiprone  or  in  the  lithotomy  posture. 
Pass  the  Sims  speculum.  Incise  the  posterior  vaginal  wall  behind  the  cervix,  in  the 
middle  line.  Tap  the  tumour  with  an  aspirator,  and  then  draw  it  through  the  incision 
with  the  finger  or  curved  forceps.  Ligature  the  pedicle  with  thin  carbolised  silk  threaded 
on  a  handled  needle,  and  divide  it  on  the  side  next  the  tumour.  Pass  a  T-shaped 
drainage  tube  into  the  wound  which  may  be  stitched  round  it  or  left  open.  Should 
the  temperature  rise  or  the  discharge  become  foetid,  irrigate  daily  with  weak  carbolic 
lotion  (1-100). 

ABDOMINAL   METHOD. 

The  question  used  to  be  discussed  as  to  the  best  time  to  operate  in  a  Abdominal 
case  of  ovarian  tumour — whether,  if  small,  one  should  wait  until  it  i 
large.     The  opinion  now  held  is  that  one  should  operate  whenever  the 
tumour  is  diagnosed  without  reference  to  its  size. 

Let  us  suppose,  then,  that  the  ovariotomist  has  a  patient — who  is  other- 
wise healthy — with  an  ovarian  tumour  free  from  adhesions,  and  that  her 
period  has  occurred  ten  days  before.  How  is  the  operation  performed  1 

If  the  patient  has  not  been  in  any  way  confined  to  bed,  it  is  probably 
better  to  delay  the  operation  till  another  period  has  passed,  in  order  to 
accustom  her  to  an  invalid's  life.  A  pulse  and  temperature  chart  should 
also  be  taken  for  a  few  days  prior  to  the  operation.  She  is  kept  on 


238  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

light  diet,  and  has  no  solid  food  for  six  hours  previous  to  the  adminis- 
tration of  chloroform.     On  the  evening  prior  to  the  operation,  castor  oil 
should  be  given  and  an  enema  used  in  the  morning. 
Requisites      The  following  are  the  requisites  for  operation  : — 
forOpera-  Chloroform  and  ether  ; 

Hypodermic  syringe ; 

Spray  (?)  5 

Carbolic  lotion ; 

Porcelain  trays  for  instruments  ; 

Sponges  (a  definite  number),  some  small  and  fixed  on  sponge- 
holders  ; 

Waterproof,  with  oval  opening  of  which  the  edges  are  coated 
with  adhesive  plaster ; 

Ordinary  knives  ; 

Probe-pointed  curved  bistoury ; 

Scissors,  straight  and  curved ; 

Spatulse ; 

Dissecting  and  dressing  forceps  ; 

Pean's  or  Wells'  artery  forceps — a  definite  number  (12)  of  pairs  ; 

Tenacula,  blunt  hooks ; 

Needles  on  fixed  handles  ; 

Aneurism  needle ; 

Fine  catgut  for  bleeding  vessels  ; 

Carbolised  silk  (Nos.  3  and  4)  ; 

Two  pairs  ovariotomy  forceps  (Nelaton's  or  Keith's)  ; 

Wells'  trocar ; 

Clamp  (in  reserve) ; 

Cautery,  actual  or  Paquelin's  ; 

Cautery-clamp ; 

Long  straight  needles,  threaded  two  on  each  suture  of  silk-worm 
gut; 

Needle-holder  with  small  needles  on  horse-hair  sutures ; 

Drainage  tubes  (glass  or  ordinary)  ; 

Reflecting  mirror ; 

lodoform,  iodoform  gauze,  salicylic  wool,  flannel  bandages. 

Assistants.  The  assistants  necessary  are  three  in  number,  viz.,  one  for  chloroform, 
one  for  instruments,  one  to  help  the  operator.  It  is  good  however  for 
the  operator  alone  to  handle  the  instruments,  and  thus  two  assist- 
ants are  sufficient.  A  trained  nurse  who  can  pass  the  catheter  and 
administer  purgative  or  nutritive  enemata,  is  necessary.  The  patient 
is  placed  on  an  ordinary  table,  of  convenient  height  and  length,  and  lies 
on  her  back.  The  table  is  placed  so  that  the  patient's  feet  are  towards 
the  window.  The  legs  and  chest  are  to  be  warmly  covered,  and  hot- 
water  bottles  should  be  laid  at  her  sides  and  feet.  The  room  should  be 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    239 

comfortably  warm.  The  best  position  for  the  operator  is  to  stand  on 
the  patient's  right  side,  with  his  back  to  her  feet  and  to  the  window. 
The  question  of  the  use  of  antiseptics  in  ovariotomy  will  be  discussed 
afterwards.  The  instruments  are  placed  near  the  operator  in  shallow 
porcelain  trays,  and  in  1-40  carbolic  solution. 

The  sponges  should  be  soft,  fine,  and  thoroughly  clean.  Twelve  are  Sponges, 
sufficient.  Some  are  small  and  on  sponge  holders  ;  one  is  large  and  flat. 
They  should  be  thoroughly  wrung  out  of  warm  1-60  solution.  The 
sponge  assistant  should  know  hoio  many  sponges  he  has,  and  should  be  sure 
that  he  has  recovered  them  all  before  the  abdominal  wound  is  dosed.  Sponges 
should  never  on  any  account  be  torn  up  during  an  operation. 

The  spray,  if  used,  should  be  placed  eight  or  ten  feet  from  the  wound  Spray, 
and  throw  out  a  finely-divided  vapour. 

Preliminaries. — The  patient,  who  has  had  a  very  light  breakfast  somePrelimi- 
hours  previously,  should  be  chloroformed  or  etherized;  the  skin  washed nanes- 
and  shaved ;  and  the  waterproof  made  to  adhere  to  the  skin,  so  that  the 
incision  shall  bisect  the   portion  exposed  through  the  oval   opening. 
This  waterproof  keeps  the  patient  dry  and  comfortable. 

The  following  are  the  steps  of  an  ordinary  operation  : — 

1.  The  abdominal  incision  ; 

2.  Evacuation  of  the  cyst  contents ; 

3.  Drawing  out  of  the  cyst  from  the  abdomen ; 

4.  Securing  of  the  pedicle ; 

5.  Treatment  of  adhesions,  and  bleeding  from  them ; 

6.  The  peritoneal  toilette  ; 

7.  Closure  of  the  abdominal  wound  ; 

8.  Drainage — when  necessary ; 

9.  Dressing  of  the  wound ; 

1 0.  After-treatment — complications. 

1.  The  abdominal  incision. — This  is  usually  four  inches  long,  is  made  Incision, 
in  the  middle  line,  and  has  its  lower  limit  about  an  inch  above  the 
symphysis.     It  passes  through — 

skin, 

fat, 

linea  alba, 

extraperitoneal  fat, 

peritoneum. 

Sometimes  the  linea  alba  is  missed,  and  the  rectus  muscle  cut  into. 
By  passing  a  probe  in  towards  the  middle  line,  the  operator  gets  the 
right  track  and  thus  avoids  bleeding.  The  extraperitoneal  fat  is  a  good 
landmark.  All  bleeding  points  are  carefully  attended  to  before  the  peri- 
toneum is  opened.  They  may  be  seized  with  Pean's  forceps  which  are 
left  on  for  a  time,  or  they  may  be  ligatured  with  catgut.  When  the 


240  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

extraperitoneal  fat  is  reached,  it  is  picked  up  with  two  Pean's  forceps  so 

as  to  get  a  short  transverse  fold ;  this  is  cut,  and  the  manoeuvre  repeated 

until  the  peritoneal  cavity  is  opened.     The  cyst  is  then  exposed. x 

Methods  of      2.  Evacuation  of  the  cyst  contents. — This  may  be  accomplished  in  vari- 

Evacua-      ous  ^&^&      Wells'  trocar  (fig.  139),  with  its  point  projected,  is  plunged 


FIG.  139. 

WELLS'  TROCAR  (J).  o,  sharp  point,  protected  by  tube  6,  which  is  projected  by 
pushing  out  thumb-piece  d  ;  c  toothed  catch  to  grasp  cyst  wall ;  gutta-percha 
tubing  is  fitted  on  to  e, 

in,  and  the  fluid  passes  along  the  thick  tube  to  a  suitable 
pail  below  the  table.  As  soon  as  the  trocar  enters  the  cyst, 
the  shield  is  pushed  out  to  guard  the  point.  The  trocar 
has  teeth  for  catching  up  the  cyst  wall.  Keith  uses  a  large 
aspirator,  so  as  to  empty  speedily.  Schroeder  used  no  trocar,  but  simply 
cuts  in  with  his  knife  and  squeezes  the  fluid  out.  The  kneed  trocar  may 
be  used  (fig.  140),  but  a  simple  large  trocar  without  toothed  catch  is 
best.  When  the  fluid  is  very  thick  it  may  not  flow,  and  have  to  be 
squeezed  or  scooped  out.  Secondary  cysts,  if  large,  are  also  per- 
forated. 

While  the  fluid  is  being  evacuated  an  assistant  keeps  up  steady  pres- 
sure on  the  abdominal  walls,  in  order  to  prevent  fluid  from  passing  in 
or  the  intestines  from  passing  out. 

Cyst  drawn  3.  Drawing  out  of  the  cyst  from  the  abdomen. — This  is  accomplished 
by  seizing  the  collapsed  walls  of  the  tumour  with  Nelaton's  (fig.  141)  or 
Keith's  forceps,  and  steadily  pulling  it  out.  The  assistant  still  keeps 


out. 


FIG.  140. 

TROCAR  FOR  TAPPING.    Tubing  is  fitted  to  side-piece. 

up  pressure.     By  this  means  the  operator  now  has  the  pedicle  at  the 
Cyst          abdominal  incision,  and  the  cyst  outside.     The  assistant  by  means  of 
sponges  keeps  back  the  intestines  should  they  attempt  to  protrude. 

1  Sometimes  the  cyst  develops  between  the  layers  of  the  broad  ligament  (v.  PI.  XL,  fig.  7), 
lifts  up  the  anterior  lamina,  and  strips  the  peritoneum  off  the  anterior  abdominal  wall.  When 
the  operator  has  cut  through  the  abdominal  muscles  he  is  puzzled  by  finding  no  peritoneum. 
Puncture  and  dragging  out  the  collapsed  cyst  will,  however,  clear  up  matters. 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    241 

Securing  of  the  pedicle. — This  is  one  of  the  most  important  steps  of  the  Securing  of 
operation.     There  are  three  methods  which  may  be  used,  viz. — 

The  clamp, 
The  cautery, 
The  ligature. 

Of  these,  the  clamp  is  now  seldom  used.  Keith  and  others  advocate 
the  cautery ;  but  the  ligature  and  dropping  back  of  the  pedicle  is  the 
favourite  and  probably  the  best  method.  The  clamp  may  be  necessary 
if  the  pedicle  is  thick. 


FIG.  141. 
N^LATON'S  FORCEPS. 

The  clamp  was  introduced  by  Jonathan  Hutchinson,  but,  as  already  said,  By  Clamp, 
is  now  yielding  to  the  ligature.     The  varieties  of  clamp  are  numerous. 
Fig.   142  shows  Wells';  it  consists  of  two  short  arms  jointed  together 
and   provided  with   a   screw   and   removable   handles.     It  is  used  as 
follows. 

The  clamp  is  held  by  its  handles  and  made  to  grasp  the  pedicle  between 
the  cyst  and  the  uterus ;  the  bars  of  the  clamp  proper  are  then  approxi- 
mated, and  the  screw  tightly  screwed  up.  The  pedicle  is  examined  to  see 


FIG.  142. 

WELLS'  CLAMP  (J),  with  removable  handles.     The  serrated  part  with  the  screw  is  the  clamp  proper. 

that  it  is  grasped  and  equally  compressed  ;  if  one  part  is  thin,  Spencer 
Wells  recommends  that  the  pedicle  be  first  secured  with  a  ligature.  The 
pedicle  is  treated  extra-peritoneally  with  the  clamp,  which  rests  on  the 
skin.  The  great  advantage  of  the  clamp  is  its  security  against  haemorr- 
hage. Its  evident  disadvantages  are  the  following  : — It  does  not  suit  all 
cases,  as  it  cannot  be  used  when  the  pedicle  is  too  large  or  too  short ;  it 
may  cause  ventral  hernia ;  it  exercises  undue  traction  on  the  uterus  ;  but, 


242  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

above  all,  it  may  cause  a  slough  deeper  down  than  the  skin,  and  the 
discharges,  passing  into  the  peritoneal  cavity,  may  do  great  mischief. 
Thus  the  mortality  was  high  (25  p.c.)  in  cases  where  the  clamp  was 
used. 

By  Cautery.      The  cautery  was  introduced,  as  a  means  of  treating  the  pedicle,  by 
Baker  Brown  of  London. 

In  order  to  use  the  cautery,  we  need  a  special  cautery-clamp  and 
either  cautery  irons  or  Paquelin's  cautery.  Keith  uses  ordinary  cautery 
irons  heated  in  a  little  charcoal  brazier.  The  cautery-clamp  has  two 
hinged  bars  provided  with  handles ;  each  bar  has  one  surface  which  is 
made  of  ivory — a  non-conductor — and  is  placed  next  the  skin  ;  the  other 
surface  is  made  of  metal ;  one  of  the  bars  has  on  its  metal  surface  a 
metal  upright  running  the  whole  length  of  the  bar.  The  pedicle  is 
seized  with  the  clamp  (ivory  side  next  to  the  skin),  and  the  screw  turned 
to  fix  it.  Then  the  cyst  is  cut  off,  so  as  to  leave  about  an  inch  of  the 
pedicle  on  the  metal  side.  The  dull  cautery  iron,  which  is  hatchet- 
shaped,  is  then  passed  firmly  over  the  surface,  in  the  angle  between  the 
horizontal  bar  and  the  upright,  until  the  pedicle  is  seared  flush  with  the 
clamp.  The  pedicle  is  now  caught  at  the  under  surface  of  the  clamp 
with  two  pairs  of  forceps,  and  the  clamp  removed.  If  all  is  right,  the 
pedicle  is  dropped  into  the  abdomen  after  the  peritoneal  toilette  is 
finished. 

By  Liga-         The  ligature  should  be  thin  carbolised  Chinese  silk  No.  3  or  4.     It  is 
used  in  the  following  way. 

A  double  silk  ligature  is  threaded  on  a  Hunt  needle.  The  pedicle  is 
transfixed  with  this,  and  the  ligature  cut.  Thus  we  have  two  ligatures 
through  the  pedicle  ;  one  is  passed  round  the  one  half  of  the  pedicle,  the 
other  round  the  other  half.  They  may  be  made  to  interlace  first  so 
as  to  make  a  figure  of  eight.  Each  is  tied  firmly  in  a  reef  knot.  The 
pedicle  is  then  seized  with  Pean's  forceps,  one  on  each  side  below  the 
ligature;  the  cyst  is  clipped  off  about  half  an  inch  on  the  cyst  side  of 
the  ligature ;  while  the  pedicle  is  still  held  up  by  the  forceps  it  can  be 
carefully  examined  to  see  if  any  bleeding  occurs.  It  should  be  noted 
whether  the  ligature  splits  the  pedicle  vertically  so  as  to  cause  bleeding; 
if  so,  the  ends  of  the  thread  can  be  made  to  surround  the  whole  pedicle 
below  this.  If  there  is  no  bleeding,  the  ligature  is  cut  short  and  the 
pedicle  dropped  into  the  pelvis. 

The  raw  end  of  the  pedicle  may  be  stitched  with  catgut  to  the  broad 
ligament,  so  as  to  prevent  its  adhering  to  and  constricting  intestine 
(Thornton). 

When  the  pedicle  is  thick  and  fleshy  it  may  require  to  be  tied  in  three 
portions  as  follows  : — Pass  a  double  thread  so  that  its  shorter  half  will 
embrace  only  one-third  of  the  pedicle;  withdraw  the  needle,  but  keep  it 
still  running  on  the  thread,  and  use  it  to  carry  the  longer  half  of  the 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    243 

thread  through  a  second  point  so  as  to  embrace  the  middle  third  of  the 
pedicle;  one  portion  of  the  longer  half  thus  forms  a  loop  round  the  middle 
third,  while  the  other  portion  embraces  the  other  third  of  the  pedicle. 
Tait's  knot  may  also  be  used  (v.  p.  211). 

After  the  pedicle  has  been  secured  by  one  of  these  methods,  the  other 
ovary  should  be  examined  and  if  cystic  removed  also. 

The  distal  portion  of  the  pedicle  does  not  slough.     According  to  Thornton,  we  may  Changes  in 
have  the  five  following  results.  Pedicle. 

(1.)  Adhesion  of  the  peritoneal  surfaces  on  opposite  sides  of  the  ligature,  and  absorption 
of  ligature. 

(2.)  Lymph  effused  over  ligature  and  end  of  stump,  formation  of  new  vessels. 

(3.)  Adhesion  of  pedicle  raw  surface  to  some  neighbouring  peritoneal  surface  and  passage 
of  blood-vessels  between. 

(4. )  Haemorrhage  from  pampinif orm  plexus  at  outer  edge. 

(5.)  No  change  or  sloughing  if  patient  dies  soon. 

5.  Treatment  of  adhesions  and  bleeding. — Adhesions  in  certain  cases  may  Treatment 
give  a  great  deal  of  trouble.     They  may  be  at  any  point  of  the  periphery  j^,^ £nd 
of  the  tumour.     When  close  to  important  viscera  (especially  the  bladder,  Bleeding, 
intestine,  or  liver)  they  are  serious.     Their  treatment  is  best  considered 
as  follows  : — (a.)  when  short,  (b.)  when  long. 

(a.)  When  easily  separable,  these  may  be  detached  by  sponging.  If 
the  cyst  is  connected  with  the  anterior  abdominal  wrall,  it  is  sometimes 
cut  into.  The  operator  then  separates  the  cyst  from  the  wall  by  pass- 
ing his  finger  in  between  them  where  the  adhesion  ceases ;  or  he  may 
evert  the  abdominal  wall,  and  strip  the  cyst  off  it  with  dissecting  forceps. 
Spencer  Wells  recommends  in  bad  cases  to  evacuate  the  cyst,  and  then, 
by  seizing  the  posterior  wall  of  the  cyst  with  a  hand  passed  into  the 
interior,  to  evert  it  and  afterwards  separate  the  adhesions.  Pressure 
with  sponges  or  ligatures  will  arrest  any  bleeding,  or  the  cautery  may 
be  applied.  If  the  bleeding  is  intractable,  a  good  plan  is  to  pinch  up 
the  abdominal  walls  at  the  bleeding  part  and  pass  a  long  straight  needle 
through  this  fold,  so  as  to  keep  the  bleeding  peritoneal  surfaces  in 
apposition. 

Adhesions  in  the  region  of  the  sacro-iliac  sychondrosis  are  dangerous 
owing  to  the  risk  of  tearing  into  the  large  veins  or  ureter.  The  possi- 
bility of  an  adhesion  to  the  tip  of  the  vermiform  appendix  must  be  kept 
in  mind. 

(&.)  When  the  adhesions  are  long,  they  may  be  ligatured  at  two  points 
close  to  the  cyst  and  divided  between  these. 

When  adhesions  to  the  bladder  are  present  great  care  must  be  taken, 
as,  in  separating  them,  the  bladder  may  be  torn  into.  If  this  happens, 
the  tear  should  be  stitched  with  fine  silk  or  catgut,  and  a  catheter  kept  in  for 
some  days.  ( Vide  under  Vesico-vaginal  Fistula.)  When  adhesions  are 
inseparable,  the  adherent  portion  of  the  cyst  may  be  ligatured  all  round 


244  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 


Peritoneal 
Toilette. 


Closure  of 
Wound. 


with  silk,  and  then  cut  beyond  the  ligatures  ;  or  it  may  be  simply  cut  all 
round  the  adherent  portion,  and  the  edges  then  cauterized. 

For  reflecting  light  into  the  pelvis  or  other  deep  parts,  an  ophthal- 
inoscopic  mirror  is  invaluable. 

6.  The  peritoneal  toilette. — This  term  is  a  convenient  one  used  by 
German   operators  to   indicate   the   cleansing   of  the  peritoneum.       It 
must  be  laid  down  as  a  cardinal  principle  in  abdominal  section  that 
no  serum  or  blood  is  to  be  left  in  the  abdomen.      The  peritoneum 
should    be   thoroughly   dry,    and    no   oozing    points    are   to   be   left. 
The   importance   of  the  toilette   cannot   be  too  strongly  insisted  on. 
Thomas  Keith,  whose   success   in  ovariotomy  is  unrivalled,  takes  the 
greatest  care  in  this  matter,  and  attributes  his  success  to  it.      Sims 
indeed  savs,   "  But  I  think  now  that  it  matters  very  little  what  we 

•/      * 

do  with  the  pedicle,  whether  we  use  the  clamp,  the  cautery,  or  the 
ligature,  provided  we  take  every  care  against  the  exudation  of  bloody 
serum  into  the  peritoneal  cavity  after  the  closure  of  the  abdominal 
wound." 

7.  Closure  of  the  abdominal  wound. — This  is  done  as  described  under 
Abdominal  Section  in  the  Appendix. 

Drainage.  8.  Drainage. — As  to  drainage,  the  rule  is  that  none  is  needed  in  simple 
cases.  This  rule  may  seem  to  the  student  to  clash  with  the  invaluable 
principle  that  every  wound  from  which  there  will  be  discharge  ought  to  be 
drained.  In  ovariotomy,  however,  the  peritoneum  is  an  absorbent  sac, 
and  the  discharge,  after  a  simple  operation,  is  absorbed  before  it  has  time 
to  putrefy  (Lister).  In  complicated  cases,  as  where  there  have  been 
many  adhesions,  this  drainage  by  absorption  is  insufficient ;  it  becomes 
also  dangerous  from  the  amount  of  serum  thrown  out,  and  the  risk  of  its 
putrefying.  External  drainage  is,  in  such  cases,  imperative.  A  per- 
forated glass  drainage-tube  is  passed  in  at  the  lower  angle  of  the  wound 
and  down  into  the  pelvis.  To  keep  the  patient  dry,  there  is  laid  over 
the  abdomen  a  piece  of  thin  rubber  sheeting  with  a  slit  in  it  through 
which  the  tube  passes.  Over  the  end  of  the  tube,  a  sponge  or  some  other 
absorbent  is  placed  and  removed  when  soaked  (Keith).  Several  pints  of 
serum  may  thus  come  away. 

9.  Dressing  of  the  wound. — Where  there  is  no  drainage,  it  is  sufficient 
to  dust  with  iodoform  and  lay  on  a  pad  of  iodoform  gauze  or  other 
antiseptic  material.  Where  a  drainage-tube  is  used  we  dust  the  wound 
as  before,  lay  over  it  a  piece  of  protective  silk  and  then  pack  round  the 
tube  some  antiseptic  absorbent  wool.  The  dressing  is  kept  in  place  by 
strips  of  plaster  or  a  loose  flannel  bandage.  If  the  pulse  and  tempera- 
ture do  not  rise  and  there  is  no  uneasiness,  the  dressing  is  left  untouched 
— in  simple  cases — for  eight  or  nine  days.  If  there  is  drainage,  the 
dressing  should  be  changed  occasionally  according  to  the  amount  of 
discharge. 


Dressing. 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    245 

10.  After-treatment:     treatment   of  complications. — Morphia    may    be  After- 
given  hypodermically,  but  only  when  necessary  (vide  p.   164).     Little  an(j  Qom. 
food  is  allowed  for  the  first  thirty-six  hours;   hot  water  should  be  given  plications. 
ad  libitum,  as  it  helps  flatus.     At  the  end  of  this  time,  milk  and  beef-tea 
are   added.     An  enema  may  be  administered  on  the  third  or  fourth 
day.     When  flatus  is  troublesome,  a  tube  may  be  passed  into  the  rectum. 
Sickness  is  often  great,  and  should  be  treated  with  mustard  poultices  over 
the  epigastrium  and  enemata  of  beef-tea  and  brandy.     If  it  persists  to 
the  third  or  fourth  day,  two  or  three  grains  of  calomel  may  be  given. 
Tait  recommends  thirty  or  forty  grains  of  Epsom  salts  each  hour  until 
the  bowels  move. 

Complications  may  be — Secondary  haemorrhage ; 
High  temperature ; 
Septicaemia. 

Secondary  haemorrhage,  if  from  the  pedicle  or  adhesions,  must  be 
treated  by  the  reopening  of  the  wound  and  application  of  ligatures. 

For  high  temperatures  the  ice-cap  is  good.  The  Americans  recommend 
the  more  wholesale  method  of  reduction  of  temperature  by  Kibbee's  ice- 
cot.  Krohne  and  Seseman  of  London  supply  very  convenient  ice-caps 
made  of  block-tin  pipe.  Quinine  in  fifteen  grain  doses  should  be  tried. 
It  is  probable  that  some  high  temperatures,  recorded  by  ovariotomists, 
have  been  due  to  the  absorption  by  the  peritoneum  of  carbolic  acid 
used  in  Listerism. 

In  cases  of  septicaemia  with  peritonitis  where  drainage  has  been 
employed,  the  peritoneal  cavity  should  be  washed  with  very  weak 
carbolic  lotion  whenever  there  seems  to  be  any  tension  or  accumulation 
of  putrid  fluid ;  the  abdominal  incision  may  require  to  be  reopened  for 
this  purpose.  The  condition  should  be  further  treated  by  iron  and 
stimulants  as  needed.  (Vide  Treatment  of  Pelvic  Peritonitis.) 

Paralysis  of  the  bowel,  with  great  distention  and  death,  has  also  been 
noted ;  as  also  death  from  heart  clot  (Tait).  Tetanus  has  also  occurred. 

The  patient  should  after  convalescence  wear  an  abdominal  belt  to 
prevent  hernia  at  the  abdominal  scar. 

ABDOMINAL    METHOD    WHEN    THE    TUMOUR    IS    PAPILLOMATOUS    AND 
EXTRAPERITONEAL. 

In  such  cases  (v.  fig.  7,  Plate  XL), -a  different  procedure  has  to  be 
adopted,  viz.  Enucleation.  The  tumour  is  tapped,  drawn  on  as  much 
as  possible,  and  its  peritoneal  covering  incised  so  as  to  include  an  elliptical 
portion.  The  finger  is  then  used  to  separate  the  tumour  from  its  capsule, 
steady  traction  facilitating  this.  Bleeding  is  arrested  with  forceps  or 
ligature.  Goodell,  who  has  given  by  far  the  most  graphic  description 
of  this  method,  advises  that  the  uterus  and  bladder  be  carefully 
defined,  and  the  separation  begun  at  the  uterine  side  of  the  tumour 


246  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

where  the  large  blood-vessels  enter.  The  difficulty  in  the  operation  is  the 
separation  in  the  pelvis,  since  the  large  veins  there  (as  well  as  the  ureter) 
are  apt  to  be  torn.  Injury  to  the  ureter  is  especially  dangerous  :  it  is 
often  not  recognised,  and,  unless  a  fistula  form,  is  fatal.  When  enuclea- 
tion  is  finished,  a  large  oozing  extraperitoneal  surface  is  left.  Its  edges 
should  be  stitched  to  the  abdominal  incision  so  as  to  close  it  off  from  the 
peritoneal  cavity,  and  a  glass  drainage-tube  passed  in.  Some,  however, 
close  this  opening  and  drain  per  vaginam. 

Cases  like  these  are  the  really  difficult  and  dangerous  ones.  The 
chance  of  return  or  peritoneal  infection  is  very  great. 

The  idea  of  this  method  of  enucleation  is  due  to  Miner  of  Buffalo, 
although  the  pathology  of  this  form  was  not  clearly  understood  then  : 
indeed,  Miner's  original  paper,  inasmuch  as  it  seemed  to  apply  to  the 
ordinary  ovarian  cyst,  was  not  very  intelligible. 

THE    RELATION    OP    LISTERISM    TO    OVARIOTOMY. 

Listerism  The  Listerian  method  of  treating  wounds  is  based  on  the  now  generally 
otomy*™'  accepted  theory  that  the  germ-laden  air  coming  in  contact  with  a  wound 
leads  to  putrefactive  changes  which  may  end  in  septicaemia.  Lister  found 
carbolic  acid  destructive  to  the  activity  of  these  germs;  and,  consequently, 
Listerism  requires  that  the  air  in  contact  with  the  wound,  and  all  else 
that  touches  it,  must  be  purified  either  with  the  spray  or  lotion.  Lister- 
ism is  in  no  sense  a  treatment  of  wounds,  but  is  a  treatment  of  wound- 
surroundings.  The  application  of  carbolic  lotion  to  a  wound  is  a  necessary 
evil,  as  carbolic  acid  is  an  irritant  and  may  be  absorbed.  In  the  cases 
treated  by  the  surgeon,  Listerism  is  of  the  greatest  value ;  and,  with 
drainage,  has  worked  the  most  mighty  revolution  in  surgery.  In  per- 
itoneal operations,  however,  its  good  is  marred  by  the  fact  that  the 
peritoneum  absorbs  the  carbolic  lotion,  and  thus  its  surface  is  irritated 
and  often  toxic  effects  ensue.  Keith,  Tait,  and  Bantock  have  therefore 
abandoned  Listerism  in  abdominal  surgery ;  but  Wells  and  Thornton 
still  carry  it  strictly  out.  Listerism  has  been  modified,  but  only  in 
this,  that  less  importance  is  now  attached  to  air-contamination  of 
raw  surfaces  during  an  operation.  Unclean  "touch"  is  the  real 
danger. 

Practically  most  ovariotomists  at  present  trust  to  modified  Listerism, 
and  to  drainage  when  necessary.  All  Listerian  precautions  should  be 
used  except  the  spray. 

OVARIOTOMY    WHEN    PREGNANCY    IS    PRESENT. 

Pregnancy      Although  pregnancy  co-exists  with  a  large  ovarian  tumour,  ovariotomy 

otomy.       should  be  performed.     In  the  paper  of  Spencer  Wells  quoted  he  gives  a 

table  of  nine  cases  where  the  pregnancy  varied  from  the  third  to  the 

seventh  month,  with  the  following  results.     Only  one  mother  died  :  the 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    247 

pregnancy  went  on  to  full  time  in  five  of  the  cases ;  in  three  the  child 
was  expelled  prematurely,  and  in  one  the  child  was  removed  at  the  opera- 
tion. Puncture  of  the  gravid  uterus  during  the  progress  of  the  operation 
must  be  guarded  against.  This  may  happen  if  the  pregnancy  has  not 
been  diagnosed  and  the  pregnant  uterus  mistaken  for  a  secondary  cyst ; 
or  it  may  be  as  in  Lee's  case  that  owing  to  a  change  of  the  position  of 
the  patient  from  the  dorsal  to  the  lateral  posture,  the  ovarian  cyst 
recedes  from  the  abdominal  incision  and  the  uterus  lies  below  it  without 
the  changes  being  noted.  When  this  accident  occurs,  the  treatment 
depends  on  the  depth  of  the  wound.  Should  the  uterine  cavity  not  be 
opened,  then  bleeding  is  arrested  by  pressure,  the  wound  stitched  with 
continuous  silk  suture.  If  the  amniotic  cavity  is  opened  into,  the 
same  treatment  may  be  adopted  (v.  Chiara's  case) ;  or  the  incision  may  be 
suitably  enlarged,  and  the  foetus,  placenta,  and  membranes  extracted. 
The  treatment  after  this  may  be  removal  of  the  uterus  by  Porro's  opera- 
tion, simple  suture  of  the  walls  with  silver  wire,  or  the  Ceesarean  section 
with  the  modification  introduced  by  Sanger.  The  question  of  the  treat- 
ment of  a  labour  complicated  with  an  ovarian  tumour  concerns  the 
obstetrician  rather  than  the  gynecologist. 

CONTRA-INDICATIONS    TO    OVARIOTOMY. 

These  are    universal   adhesions  and   malignant   disease.      Ordinary  Contra- 
ascites,  kidney  disease,  or  heart  disease,  is  not  a  contra-indication  unless111' 
far  advanced.     Prognosis  should  be  careful  in  these  cases.     In  some 
fatal  cases  it  has  been  found  on  post  mortem  that  the  kidneys  were  small 
and  granular  from  interstitial  inflammation.     This  may  be  present  while 
there  is  no  albumen  in  the  urine.     There  is  usually  a  pulse  of  high 
tension  and  cardiac  hypertrophy  (v.  Mahomed's  articles). 

COURSE   AND    RESULTS    OP    OVARIAN    TUMOURS    WHEN    LEFT   ALONE. 

In  some  rare  cases  the  operator  is  unable  to  remove  the  cyst  after  he  Natural 
has  begun  his  operation.     He  may  then  stitch  the  cyst  edges  to  theovafrian 
abdominal  walls  carefully  closing  it  off  from  the  peritoneum.     The  best  Cysts, 
results  by  this  method  are  got  in  dermoid  and  parovarian  cysts :  they 
are  not  good  in  ordinary  ovarian  cystomata. 

Adhesions  may  be  set  up  as  the  result  of  chronic  peritonitis  arising 
from  pressure  or  tapping.  Occasionally  the  cyst  bursts,  and  in  the  case 
of  the  ordinary  ovarian  tumour  we  may  get  rapid  death  or  the  condition 
termed  Pseudomyxoma  peritonei  by  Werth  (v.  p.  221).  When  par- 
ovarian  tumours  burst,  the  fluid  is  usually  non-irritating  and  is  absorbed 
by  the  peritoneum,  the  patient  thus  becoming  cured.  Matthews  Duncan 
and  others  have  recorded  cases  of  burst  ovarian  tumour  rapidly  becoming 
fatal.  Waxy  disease  of  the  liver,  kidneys,  etc.,  may  result  in  those 


248  AFFECTIONS  OF  FALLOPIAN  TUBES  AND  OVARIES. 

cases  where  the  tumour  suppurates  and  discharges  into  the  bowel  or 
through  the  skin. 

Torsion  of  the  pedicle  to  a  slight  extent  is  often  noticed  in  ovarian 
tumours.  When  the  torsion  is  so  great  as  to  cut  off  the  blood  supply 
from  the  cyst,  we  get  gangrene  of  the  tumour,  and  in  some  cases  very 
serious  symptoms,  viz.,  peritonitis,  vomiting,  and  severe  abdominal 
pains.  Wiltshire  of  London  was  the  first  to  operate  for  this  condition, 
and  recently  Lawson  Tait  has  operated  successfully  in  three  cases.  His 
paper  should  be  consulted  for  details.  It  is  interesting  to  note  that  the 
tumours  so  rotated  are  usually  right-sided,  and  not  necessarily  ovarian. 
The  usual  explanation  of  the  rotation  is  that  it  is  caused  gradually  by 
the  fsecal  contents  passing  down  the  rectum.  Tait's  book  and  Thornton's 
paper  may  be  consulted  for  fuller  details. 

If  peritonitis  occur  before  the  tumour  is  removed,  ovariotomy  should 
be  at  once  performed.  Keith  was  the  first  to  do  this  successfully. 

The  course  and  results  of  ovarian  tumours  when  left  alone  can  fortu- 
nately not  now  be  studied.  The  picture  of  ovarian  disease  running  its 
course  unchecked,  so  eloquently  described  by  West,  is  happily  now 
almost  unknown. 

"  We  have  symptoms  of  the  same  kind  as  we  see  towards  the  close  of 
every  lingering  disease,  betokening  the  gradual  failure,  first  of  one  power, 
then  of  another  ;  the  flickering  of  the  taper,  which,  as  all  can  see,  must 
soon  go  out.  The  appetite  becomes  more  and  more  capricious,  and  at 
last  no  ingenuity  of  culinary  skill  can  tempt  it,  while  digestion  fails  even 
more  rapidly,  and  the  wasting  body  tells  but  too  plainly  how  the  little 
food  nourishes  still  less  and  less.  The  pulse  grows  feebler,  and  the 
strength  diminishes  every  day,  and  one  by  one  each  customary  exertion 
is  abandoned.  At  first  the  efforts  made  for  the  sake  of  the  change  which 
the  sick  so  crave  for  are  given  up ;  then  those  for  cleanliness  ;  and  lastly, 
those  for  comfort — till  at  length  one  position  is  maintained  all  day  long 
in  spite  of  the  cracking  of  the  tender  skin,  it  sufficing  for  the  patient 
that  respiration  can  go  on  quietly,  and  she  can  suffer  undisturbed. 
Weariness  drives  away  sleep,  or  sleep  brings  no  refreshing.  The  mind 
alone,  amid  the  general  decay,  remains  undisturbed  ;  but  it  is  not 
cheered  by  those  illusory  hopes  which  gild,  though  with  a  false  bright- 
ness, the  decline  of  the  consumptive ;  for  step  by  step  death  is  felt  to  be 
advancing ;  the  patient  watches  his  approach  as  keenly  as  we,  often 
with  acuter  perception  of  his  nearness.  We  come  to  the  sick  chamber 
day  by  day  to  be  idle  spectators  of  a  sad  ceremony,  and  leave  it  humbled 
by  the  consciousness  of  the  narrow  limits  which  circumscribe  the 
resources  of  our  art."  (Quoted  by  Spencer  Wells.) 

The  question  of  the  mortality  after  ovariotomy  is  a  complex  one, 
owing  to  differences  in  cases  and  also  because  the  use  of  the  clamp  in 
early  operations  unduly  raised  the  death-rate.  Of  late  years  the  mor- 


OPERATIVE  TREATMENT  OF  OVARIAN  TUMOURS.    249 

tality  has  fallen  considerably,  chiefly  owing  to  the  use  of  the  intraperi- 
toneal  treatment  of  the  pedicle  (ligature  or  cautery)  and  greater  care  as 
to  sponges  and  surroundings.  Keith  has  had  32  cases  with  one  death  : 
and  also  76  consecutive  cases  without  a  death.  Lawson  Tait  records  a 
series  of  101  cases  with  3  deaths. 

Sir  Spencer  Wells'  Statistics  in  1000  cases  are  given  in  his  well- 
known  work.  Thornton  gives  his  mortality,  with  strict  Listerian  pre- 
cautions, as  2  p.c. 


SECTION    Y. 

AFFECTIONS   OF   THE    UTERUS. 

rriHERE  are  three  periods  during  which  morbid  conditions  of  the 
-*-      uterus  arise. 

1.  The  period  of  evolution  or   development — from   the    ovum   up    to 
puberty.     During  this  stage  they  appear  as  anomalies  in  development — 
before  birth  or  during  childhood.      They  produce  no  marked  symptoms, 
but  a  recognition  of  their  existence  is  important  as  regards  the  future 
history  of  the  patient. 

2.  The  period  of  physiological  activity — from  puberty  to  the  meno- 
pause.   During  this  stage  there  occur  in  the  uterus  the  morbid  processes 
of  acute  and  chronic  inflammation,  and  of  new-formation  or  tumour- 
growth  ;  on  account  of  its  mobility,  the  uterus  is  also  liable  to  various 
forms  of  displacement.     These  pathological  processes  give  rise  to  symp- 
toms of  themselves,  and  also  from  their  effect  on  the  normal  functions  of 
the  uterus — menstruation,  conception,  and  pregnancy.     During  parturi- 
tion the  cervix   uteri  is   frequently  lacerated,   and  this  may  be   the 
starting-point  of  important  pathological  conditions. 

3.  The  period  of  senile  involution  or  retrogressive  development — from 
the  menopause  to  death.     The  term  involution  is  generally  used  in  the 
restricted  sense  of  the  process  which  occurs  after  childbirth,  but  it  is  the 
only  one  which  conveniently  expresses  the  retrogressive  changes  after 
physiological  activity  has  ceased.     During  this  stage,  the  most  important 
pathological  process  is  that  of  malignant  new-formation. 

Accordingly  the   following   subjects  have  to  be  considered  in  this 
Section  : — 

CHAPTER     XXV.  Malformations  of  the  Uterus. 

„         XXVI.  Atresia  and  Stenosis  of  the  Cervix  Uteri. 

„        XXVII.  Atrophy  of  the  Cervix  and  Uterus :    Superinvolu- 

tion. 
„      XXVIII.  Hypertrophy  of  the  Cervix  ;  Amputation. 

,,         XXIX.  Laceration  of  the  Cervix  and  its  Consequences. 
XXX.  Chronic  Cervical  Catarrh. 


252  LIST  OF  CHAPTERS. 

CHAPTER      XXXI.  Endometritis. 

„  XXXII.  Metritis,  Acute  and  Chronic  ;  Subinvolution. 

„         XXXIII.  Displacements  of  the  Uterus  :  Anteflexion ;  Ante- 
version  ;  Retroversion ;  Retroflexion. 
„         XXXIV.  Inversion  of  the  Uterus. 

„  XXXV.  Tumours  of  the  Uterus.     Fibroid  Tumour  :  Path- 

ology and  Etiology. 

„         XXXVI.  Fibroid  Tumour  of  the  Uterus :    Symptoms  and 
Diagnosis. 

,,       XXXVII.  Fibroid  Tumour  of  the  Uterus  :  Treatment. 

„      XXXVIII.  Fibrocystic  Tumour  of  the  Uterus, 
XXXIX.  Polypi  of  the  Uterus. 

„  XL.  Carcinoma    Uteri    (of    Cervix)  :    Pathology   and 

Etiology. 

„  XLI.  Carcinoma    Uteri   (of    Cervix) :    Symptoms   and 

Diagnosis. 

„  XLII.  Carcinoma  Uteri  (of  Cervix) :  Treatment. 

„  XLIII.  Carcinoma  Uteri  (of  Body). 

„  XLIV.  Sarcoma  Uteri. 


CHAPTER   XXV. 

MALFORMATIONS   OF   THE    UTERUS. 

LITERA  TURE. 

Barnes  —  Diseases  of  Women  :  London,  1878,  p.  462.  Dirner  —  Ein  Fall  von  Uterus 
didelphys,  etc.  :  Archiv  f.  Gyn.,  XXII.,  S.  463.  Dos  Santos,  Las  Casas  —  Missbil- 
dungen  des  Uterus  :  Zeit.  f.  Geb.  u.  Gyn.,  XIV.  S.  140.  Kussmaul  —  Von  dem 
Mangel,  der  Verkiimmerung  und  Verdoppelung  der  Gebarmutter,  etc.  :  "VVurzburg, 
1859.  Macdonald,  Angus  —  Case  of  Pregnancy  in  the  Left  Horn  of  a  Bifurcated 
Uterus,  etc.  :  Ed.  Med.  Jour.,  April  1885.  Mayerhofer  —  Die  Entwickelungsfehler 
der  Gebarmutter  :  Billroth's  Handbuch  fur  Frauenkrankheiten,  Stuttgart,  1878. 
Schroeder  —  Krankheiten  der  weiblichen  Geschlechtsorgane  :  Leipzig,  1878,  S.  33. 
Sechcyron  —  Du  Cloisonnement  Pelvien  Ante'ro-Posterieur  :  Annal.  de  Gyn.,  XXI. 
441  and  XXIII.  247  et  seq.  Simpson,  A.  E.  —  Case  of  Double  Uterus  :  Ed.  Med. 
Jour.,  1864,  p.  957.  Turner  —  Malformations  of  the  Organs  of  Generation:  Edin. 
Med.  Jour.,  June  1865  and  May  1866.  The  standard  work  is  that  of  Kussmaul. 
The  literature  is  given  by  Mayerhofer  and  Dos  Santos.  See  also  Index  of  Recent 
Gynecological  Literature  in  Appendix  for  isolated  cases. 

WHAT  is  usually  described  as  "  a  malformation  "  is  really  a  nonformation  Relation  of 
of  one  part,  involving  a  relative  disproportion.      Of  this  we  have 


illustration  in  the  uterus.  The  one-horned  uterus  is  not  a  malforma-  Develop- 
tion,"  if  by  this  term  we  mean  that  the  part  which  is  present  is 
maldeveloped  ;  the  condition  is  a  result  of  the  wowformation  of  the 
other  horn  and  intervening  fundus.  It  is  misleading  also  to  speak  of  a 
"  double  uterus  ;"  the  structure  thus  described  is  really  one  uterus, 
in  which  the  halves  have  not  united  into  a  whole.  The  word  as  used, 
therefore,  means  an  incomplete  result,  not  a  defective  process.  Mal- 
development  is  a  contradiction  in  terms,  there  can  only  be  arrested 
development. 

Malformations  must  be  studied  in  connection  with  the  normal 
development  of  the  organ.  In  this  way,  they  become  at  once  intel- 
ligible. There  are  two  processes  in  the  progression  of  an  organ  to  its 
mature  form  —  development  and  growth.  There  are  therefore  two  causes 
which  together  operate  in  producing  malformations  —  arrested  develop- 
ment and  arrested  growth.  The  period  of  development  of  the  uterus, 
by  which  we  mean  formation  of  parts,  extends  up  to  the  twentieth 
week  ;  the  period  of  growth  is  much  longer,  and  extends  to  the 
twentieth  year. 

The  student  should  not  pass  over  this  section  of  the  subject  as  of 
little  importance.  To  the  practical  man,  malformations  seem  of  little 


254 


AFFECTIONS  OF  UTERUS. 


Uterus 
absent  or 
rudi- 
mentary. 


value  because  he  has  no  power  of  modifying  the  result.  To  the 
scientific  man  they  are,  however,  of  the  greatest  interest  as  furnishing 
him  with  permanent  impressions  of  the  transitional  states  of  develop- 
ment ;  they  are  development  caught  in  the  act  and  fixed  permanently 
for  after-investigation.  In  this  chapter  we  recommend  the  student  to 
read  Etiology  before  Pathology. 

PATHOLOGY. 

Complete  absence  of  the  uterus  is  an  extremely  rare  occurrence,  and 
cannot  be  demonstrated  except  on  post-mortem  examination.  It  has 
been  described  only  in  cases  of  foetal  monstrosities.  A  rudimentary 
condition  sometimes  occurs ;  in  this  the  uterus  is  represented  by  a 
band  of  muscular  fibre  and  connective  tissue  on  the  posterior  wall  of 
the  bladder  (fig.  143),  and  the  peritoneum  forms  a  single  pouch  between 
the  bladder  and  the  rectum  (fig.  144). 


FIG.  143. 

RUDIMENTARY  UTERUS  (Veil).    So.  Sacrum  ;  U  Solid  Rudiment  of  Uterus  ;  h  Rudimentary  Horn  ; 
£  Bladder  ;  0  Ovary  ;  T  Fallopian  Tube  ;  r  Round  Ligament. 

In  the  uterus  bipartitus  (fig.  145),  rudimentary  horns  are  present  and 
are  solid  or  hollow.  The  cervix  is  represented  by  a  fibrous  band  which 
connects  the  horns  with  one  another  and  with  a  rudimentary  vagina. 
The  ovaries  are  sometimes  well  developed,  so  that  ovulation  takes  place. 
The  breasts  and  external  genitals  may  be  fully  formed. 

The  uterus  unicornis  (fig.  147)  may  exist  with  or  without  a  rudi- 
mentary second  horn.  The  vaginal  portion  of  the  cervix  is  small ;  the 
palmse  plicatae  within  the  cervical  canal  are  most  marked  towards  the 
non-developed  side.  The  body  of  the  uterus  is  of  disproportionate 
length  and  curves  towards  one  side.  The  fundus,  by  which  we  under- 
stand the  fully-developed  horn,  is  small  and  tapering ;  it  has  only  one 
Fallopian  tube  and  ovary  connected  with  it.  On  the  convex  side  of 
the  somewhat  curved  body  is  the  representative  of  the  other  horn  which 
is  either  solid  or  hollow ;  it  is  connected  with  the  developed  one  by 
fibrous  tissue  which  may  or  may  not  form  a  pervious  canal.  Connected 


MALFORMA  TIONS. 


255 


with  this  rudimentary  horn  are  the  Fallopian  tube  and  ovary  of  the 
same  side,  which  are  sometimes  perfectly  developed.  In  examining 
preparations  of  this  and  other  uterine  malformations,  it  is  sometimes 
difficult  to  determine  what  is  rudimentary  horn  and  what  is  Fallopian 
tube.  Here  development  furnishes  us  with  a  guide.  The  insertion  of 
the  round  ligament  indicates  the  point  up  to  which  the  ducts  of 
Miiller  are  to  be  formed  first  into  uterine  horn  and  then  into  fundus 


FIG.  144. 

The  same  in  its  relation  to  the  Pelvic  Organs.     U  Rudiment  of  Uterus  on  the  posterior  wall  of 
Bladder.     The  Peritoneum  forms  one  pouch  between  Bladder  and  Rectum.    (Schroeder) 

uteri.     Accordingly,  on  examining  such  preparations  we  determine  the  Round 
point  of  attachment  of  the  round  ligament ;  all  below  this  is  uterine  horn,  j^^es 
all  above  it  is  Fallopian  tube.      Associated  with  this  malformation  weJuncti°n  ° 

sometimes  find  absence  or  rudimentary  condition  of  the  kidney  of  the  Horn16 

and  Tube. 


FIG.  145. 

UTERUS  BIPARTITUS  (Rokitansky).     V  Vagina  ;  U  Uterus  ;  h  Rudimentary  Horn  ;  0  Ovary ; 
T  Tube  ;  r  Round  Ligament ;  &  Broad  Ligament. 

same  side,  since  the  development  of  the  renal  is  closely  connected  with 
that  of  the  generative  system. 

In  the  uterus  didelphys  the  two  halves  of  the  uterus  remain  separate  uterus 
throughout  their  course  ;  the  vagina  may  be  absent,  single,  or  double.  Didelphys. 
It  is  a  rare  condition  in  the  living  adult  female ;  Dirner  gives  only  seven 
reported  cases  of  this  condition  in  the  adult  with  no  other  maldevelop- 


56 


AFFECTIONS  OF  UTERUS. 


inent  and  having  normal  sexual  functions,  and  Dos  Santos  gives  refer- 
ences to  three  others  in  addition  to  four  seen  at  the  Berlin  University 
Clinique. 

Fig.  146  shows  a  uterus  described  by  Paterson  and  Coats  from  a 
patient  who  died  a  fortnight  after  the  delivery  of  a  seven  months'  child. 


FIG.  146. 

UTERUS  DIDELPHYS  (Coats). 

There  are  apparently  two  uteri,  which  are  separate,  but  open  into  a 
common  vagina ;  they  are  of  nearly  equal  size — the  right  which  con- 
tained the  foetus  measuring  5  in.  and  the  left  4f  in.  in  length,  and 
being  respectively  2|  and  If  in.  in  breadth. 


K 


FIG.  147. 


UTERUS  UNICORNIS  (Schroeder).  R  Right  Side  ;  L  Left  Side.  The  left  horn  (h)  is  well  developed 
and  communicates  with  the  Uterine  Cavity.  The  right  horn  is  in  the  form  of  an  elongated 
band  ;  its  point  of  connection  with  the  Fallopian  tube  is  indicated  by  the  insertion  of  the  round 
ligament  which  is  hypertrophied.  Other  letters  as  in  preceding  diagrams. 

Uterus  By  uterus  tiicornis  we  understand  that  the  separation  into  two  horns  is 

distinctly  visible  externally.     Of  this  there  are  various  degrees,  from  a 
mere  depression  at  the  middle  of  the  fundus  to  a  well-marked  bifurcation, 


MALFORMATIONS. 


257 


which  rarely  extends  lower  than  the  os  internum ;  the  further  down  the 
separation  extends,  the  more  obtuse  is  the  angle  between  the  divergent 
horns.  There  is  occasionally  a  fold  of  peritoneum,  containing  muscular 
fibre  and  blood-vessels,  running  from  the  bladder  to  the  rectum  in  the 
hollow  between  the  horns.  In  addition  to  this  external  division,  the 
separation  is  usually  carried  further  down  by  an  internal  septum  which 
may  extend  to  the  os  externum. 


FIG.  148. 

UTERUS  BICORNIS  UNICOLLIS  (Sclroeder).    r  Bound  Ligament. 

In  the  uterus  septus  (fig.  149)  there  is  no  external  indication  of  the  Uterus 
internal  division.     The  uterus  is  divided  by  a  septum  beginning  at  the  ep  us' 


UTERUS  SEPTUS  IN  VERTICAL  TRANSVERSE  SECTION  (Kussmaul).  U  (Uterus)  placed  on  septum  which 
divides  Cavity  into  two  lateral  portions ;  T  Fallopian  Tubes ;  V  Vagina  divided  into  lateral 
cavities  by  prolongation  of  septum  downwards. 


fundus  uteri  and  extending  downwards  for  various  distances,  sometimes 
as  far  as  the  os  externum.     It  is  otherwise  normal. 
R 


258 


AFFECTIONS  OF  UTERUS. 


Infantile         The  infantile  uterus  (fig.  150)  is  characterised  by  shortness  of  body  and 

Uterus.      disproportionate  length  of  cervix  ;  in  fact  the  relative  lengths  of  body  and 

cervix  remain  the  same  as  at  birth,  from  which  the  name  "  infantile " 

is  derived.     The  cervix  (1  \  inches  long)  is  two  or  even  three  times  the 

length  of  the  body  (J  in.  to  f  in.).      The  whole  uterus  is  smaller  than 


FIG.  150. 

INFANTILE  UTERUS  (Schroeder). 

normal.     The  walls  (specially  those  of  the  body)  are  thin  and  the  cavity 

is  small. 

Congenital      The  term  congenital  atrophy  is  applied  to  cases  in  which  the  propor- 
Uterus.       tions  of  body  and  cervix  are  of  the  normal  virgin  type,  while  the  organ 


FIG.  151. 
PRIMARY  ATROPHY  oy  THE  UTERUS  (  Virchow). 

as  a  whole  is  atrophied  (fig.  151).  An  excess  of  connective  tissue  is 
present  in  the  walls,  which  makes  their  consistence  firmer.  This  mal- 
formation occurs  in  scrofulous  and  chlorotic  patients  and  with  cretinism, 
and  is  often  associated  with  hysteria  and  epilepsy. 


MALFORMATIONS.  259 


ETIOLOGY    AND    CLASSIFICATION. 

Malformations  differ  according  to  the  period  at  which  development  and  Five 
growth  are  arrested,  and  the  extent  to  which  they  are  interfered  with.  J^""]^!,.111 
There  are  five  periods  in  development  and  growth  (Furst],  which  can  bementof 
easily  remembered  when  we  bear  in  mind  the  division  of  the  period  of  . 
intra-uterine  life  into  ten  lunar   months.      In  the  first  period,   which 
extends  over  the  first  and  second  lunar  months  (from  fertilization  to  the 
eighth  week),  the  septum  between  the  adjacent  ducts  of  Miiller  is  as  yet 
unbroken.     By  the  end  of  the  second  period,  which  corresponds  to  the 
third  month  (i.e.  eighth  to  twelfth  week),  the  septum  has  entirely  dis- 
appeared ;  but  the  upper  portions  of  the  ducts  remain  distinctly  separate, 
forming  the  horns  of  the  uterus  and  the  Fallopian  tubes.     During  the 
third  period,  fourth  and  fifth  months,  the  angle  between  the  uterine  horns 
disappears  so  that  the  base  of  the  uterus  becomes  flat.     In  the  fourth 
period,  last  five  months,  the  flattened  end  of  the  uterus,  between  the 
Fallopian  tubes,  becomes  arched  through  the  development  of  the  fundus. 
The  fifth  period  extends  from  birth  to  puberty.     During  this  period  no 
important  change  takes  place  till,  at  puberty,  the  uterus  passes  from  the 
infantile  to  the  virgin  form.     It  does  not,  however,  cease  to  grow  till  the 
twentieth  year. 

We  are  not  yet  in  a  position  to  refer  each  malformation  in  detail  to  Classifica- 
its  proper  period ;  but  the  more  perfectly  we  are  able  to  do  this  the  more 
satisfactory  will  our  classification  be.     At  present  we  separate  the  first  tions. 
four  periods  from  the  fifth,  and  speak  of  the  period  of  foetal  life  in  con- 
tradistinction to  the  period  of  childhood.     This  forms  the  basis  of  our 
classification. 

1.  MALFORMATIONS  ARISING  DURING  FCETAL  LIFE.  Of  these  there  are 
the  following  : — complete  absence  or  rudimentary  condition  of  the  uterus ; 
the  uterus  bipartitus,  produced  by  a  development  of  only  the  upper  parts 
of  the  ducts  of  Miiller  into  rudimentary  horns  of  the  uterus  and  Fallopian 
tubes  ;  the  uterus  unicornis,  due  to  the  development  of  only  one  duct ; 
the  uterus  didelpkys,  due  to  the  development  of  the  ducts  separately, 
without  coalescence ;  the  uterus  bicornis,  in  which  the  ducts  coalesce 
below,  and  the  horns  remain  un-united  by  a  fundus  above  ;  the  uterus 
septus,  in  which  the  coalescence  of  the  ducts  and  development  of  the 
fundus  takes  place  so  that  the  uterus  appears  normal  externally  while 
internally  the  septum  has  persisted.  These  last  three  are  sometimes 
spoken  of  as  varieties  of  the  double  uterus  or  uterus  duplex.  The  associa- 
tion of  an  antero-posterior  reduplicature  of  the  peritoneum  with  some 
cases  of  uterus  bicornis  is  of  interest  from  an  etiological  point  of  view, 
pointing  back  to  some  mechanical  cause  which  kept  the  ducts  of  Miiller 
from  blending.  It  is  interesting  that  a  rudimentary  condition  of  the 
uterus  has  been  observed  in  more  than  one  member  of  the  same  family. 


260  AFFECTIONS   OF   UTERUS. 

2.  MALFORMATIONS  ARISING  DURING  CHILDHOOD.  Of  these  there  are 
the  following : — the  uterus  infantilis,  in  which  the  uterus  does  not  undergo 
the  development  which  should  take  place  at  puberty,  but  remains  of  the 
same  type  as  it  was  at  birth ;  congenital  atrophy  of  the  uterus,  in  which 
it  assumes  the  virgin  type  but  the  organ  as  a  whole  is  atrophied. 

SYMPTOMS. 

The  symptoms  of  malformation  consist  in  an  impairment  of  function, 
and  hence  do  not  appear  until  puberty. 

In  the  external  appearance  of  the  patient  there  is  not  necessarily  any- 
thing to  attract  attention.  The  figure,  features,  temperament,  and  voice 
are  of  the  feminine  type,  even  though  the  uterus  is  not  developed.  The 
mammae  may  be  fully  formed.  The  external  genitals  may  be  found  well- 
formed,  as  their  development  is  independent  of  the  internal  organs.  It 
is  rare,  on  the  other  hand,  to  find  a  normal  vagina  present  when  the 
uterus  is  rudimentary.1 

Sometimes      Complete  absence  and  rudimentary  condition  of  the  uterus  may  give 
symptoms  r'se  ^°  no  l°cal  symptoms,  except  the  non-appearance  of  menstruation, 
absent.       If  the  ovaries  are  developed,  ovulation  with  associated  monthly  disturb- 
ance is  present  and  the  accumulation  of  menstrual  blood  in  a  rudimentary 
horn  may  call  for  operative  measures  to  form  a  channel  for  its  escape. 
Even  on  entering  married  life  the  condition  need  not  necessarily  attract 
attention ;   if  the  vagina  be  not  well  developed,  the  urethra  becomes 
dilated  so  as  to  take  its  place. 

Cause  of  In  the  uterus  unicornis,  menstruation,  conception  and  pregnancy  may 
symptoms  £°  on  undisturbed  in  the  developed  horn.  It  is  the  imperfectly  developed 
horn  which  gives  rise  to  symptoms — the  result  of  the  retention  of  men- 
strual blood  and  of  the  products  of  conception.  If  the  mucous  membrane 
of  this  horn  discharge  blood  periodically  and  there  be  no  communication 
with  the  uterus  to  allow  of  escape,  the  blood  collects  and  produces  a  dis- 
tended sac — a  very  rare  occurrence.  It  is  of  great  interest  to  note  that 
we  may  have  a  fertilized  ovum  growing  in  the  isolated  horn  ;  we  have 
not  space  here  to  discuss  how  this  interesting  condition  is  produced 
(fig.  152).  Pregnancy  has  also  occurred  in  the  one-half  of  a  uterus 
didelphys,  and  the  empty  half  formed  an  obstruction  to  labour  at 
term.2 

Uterus  bicornis  and  uterus  sept  us  produce  no  symptoms,  unless  one 
half  of  the  partitioned  uterus  does  not  open  into  the  cervical  canal — in 
which  case  hsematometra  occurs  at  puberty  (v.  Chap.  XLV.).  The 
statement  that  the  patient  menstruates  regularly  throws  the  practi- 
tioner off  his  guard.  He  should  remember  that  the  menstrual  blood 
may  flow  undisturbed  from  one  half  of  the  uterus  while  it  is  accumulating 

1  As  in  cases  by  Kalm-Bensinger'a  Centralb.  f.  Gyn.,  1887,  S.  377  ;  Grechen,  ib  8.  493  •  Munde  ib. 
8.  670 ;  Steinschneider,  ib.  1888,  S.  49 ;  Zweifel,  ib.  S.  474. 

*  Dos  Santos,  op.  cit.     See  also  case  by  Litechkus,  Zeits.f.  Geb.  u.  Gyn.,  XIV.  a  369. 


MALFORMATION'S.  261 

in  the  other.  In  both  of  these  forms  we  have  two  possible  seats  for  a 
growing  ovum  (fig.  153);  and  this  accounts  for  super-foetation,  and  those 
curious  cases  in  which  an  ovum  has  been  expelled  in  the  course  of  a 
pregnancy  which  went  on  to  full-time.1  When  the  uterus  is  double, 
abortion  and  premature  labour  are  more  frequent ;  the  septum  also  causes 
difficulty  in  delivery,  and  involution  progresses  more  slowly.  It  has  been 
noted  that  a  decidua  forms  in  the  empty  half  of  the  uterus,  as  it  does  in 
extra-uterine  gestation,  and  may  be  expelled  in  the  puerperium. 

The  anomaly  of  menstruation  during  pregnancy  has  also  been  thus 
explained ;  Henderson  found  a  double  uterus  in  a  patient  who  men- 
struated regularly  during  two  of  her  pregnancies — the  flow  coming 
probably  from  the  empty  cavity. 2 

The  uterus  iiifantilis  and  the  congenitally  atrophic  uterus  are  char- 
acterised by  the  absence  or  scantiness  of  the  menstrual  flow  and  the 
constitutional  nervous  disturbance  which  is  usually  associated  with 
them. 

DIAGNOSIS. 

Complete  absence  of  the  uterus  cannot  be  diagnosed  with  certainty  in  Diagnosis 
the  living  subject.  A  rudimentary  condition  may  be  present,  and  yet  °f  u^ruT 
not  be  detected  on  the  most  careful  examination.  To  examine  cases  in 
which  this  condition  is  suspected,  we  first  pass  a  sound  into  the  bladder 
and  then  with  one  or  two  fingers  of  the  right  hand  in  the  rectum  palpate 
the  tissues  which  lie  between  the  sound  and  the  fingers.  It  is  evident 
that  in  such  a  condition  as  is  represented  in  fig.  144  the  rudiment  of  the 
uterus  may  escape  observation,  or  be  considered  as  a  thickening  of  the 
posterior  wall  of  the  bladder.  We  now  remove  the  sound  from  the 
bladder,  as  it  only  reaches  to  a  limited  height  in  the  pelvis,  and  with  the 
left  hand  on  the  abdomen  make  a  careful  recto-abdominal  examination 
which,  under  chloroform,  gives  much  more  definite  information.  If  we 
feel  two  bodies  laterally  without  any  distinct  body  between,  it  is  impossible 
to  say  whether  these  are  rudimentary  horns  or  ovaries. 

The  diagnosis  of  the  one-horned  uterus  is  not  easy.     The  points  to  Diagnosis 
rely  on  are  the  following :  the  fundus  turns  to  one  side  of  the  pelvis,  isunkornis 
tapering,  and  has  only  one  ovary  connected  with  it.     The  rudimentary 
horn  and  the  other  ovary  lie  removed  from  it. 

The  uterus  didelphys  is  rare.     A  groove  on  the  external  surface  of  Of  Uterus 
the  uterus  separating  it  into  lateral  halves,  so  that  sounds  can  be  passed    J  e  p  ys' 
into  the   separate   cavities  without  coming  in  contact,  indicates  this 
condition. 

The   uterus  bicornis  is  a   comparatively  frequent   condition,  and  if  Of  Uterus 
well  marked  is   easily  recognised.       Unusual   breadth  of  the   fundus, 

1  As  in  Gray's  case  (Glas.  Med.  Journ.,  XXXI.,  p.  182)  where  an  abortion  took  place  in  the  sixth 
week  of  a  normal  pregnancy,  and  Ross's  (Edln.  Med.  Journ.,  1885,  p.  131)  where  there  was  a  twin 
abortion  in  the  sixth  month  and  a  full-time  labour  three  months  later. 

z  Glas.  Med.  Journ.  XIX.  p.  276. 


262 


AFFECTIONS  OF  UTERUS. 


Diagnosis 
of  Uterus 
Septus. 


with  a  slight  depression  in  the  centre,  points  to  a  minor  degree  of  this 
deformity. 

The  uterus  septus  is  easily  diagnosed  if  the  septum  extend  as  far  as 
the  os  externum,  so  as  to  be  within  reach  of  the  examining  finger.     If 


the  septum  does  not  extend  so  far,  the  condition  may  not  be  detected  as 
there  is  no  change  in  the  external  form  to  direct  attention  to  the  internal 
malformation.  The  sound  may  pass  with  equal  ease  into  either  cavity, 
or  always  into  the  same,  and  thus  furnish  no  indication.  In  a  case  that 


MALFORMA  TIONS. 


263 


came  under  our  own  observation  the  patient  was  examined  frequently 
during  life,  bimanually  and  with  the  sound,  and  the  uterus  pronounced 
normal.  At  the  post-mortem,  the  external  appearance  of  the  uterus  was 
normal  ;  it  was  only  on  cutting  into  it  that  it  was  observed  that  the 
cavity  was  divided  into  two  portions  by  a  septum  which  extended  to 
the  os  internum. 

The  uterus  infantilis  and  the  congenitally  atrophic  uterus  are  re-  Of  Infantile 
cognised  by  their  smallness.     This  is  most  distinctly  made  out 


the  finger  in  the  rectum,  the  uterus  being  at  the  same  time  drawn  Atrophic 
down  and  fixed  with  the  volsella.     The  well-developed  vaginal  portion 


FIG.  153. 

UTERUS  SEPTUS  (posterior  view)  FROM  A  WOMAN  WHO  DIED  IN  THE  PUERPERIUM  (fruveilhier).  The 
Uterine  Cavity  is  divided  by  a  septum  which  extends  to  the  os  externum.  The  left  half  (1)  is 
strongly  developed  and  contained  the  foetus.  The  right  half  (2)  was  empty. 

and  the  unusual  length  of  the  cervix,  as  felt  per^  rectum,  enable  us  to 
diagnose  the  infantile  from  the  congenitally  atrophic  uterus. 

With  regard  to  differential   diagnosis,  gestation  in  a  detached  horn  Differential 
becomes  a  condition  of  great  importance  to  the  gynecologist  when  i 
simulates  a  fibroid  tumour.     The  occurrence  of  irregular  haemorrhages 
from  the  empty  uterine  cavity,  the  absence  of  the  foetal  heart  and  uterine 
souffle  when  the  foetus  is  dead,  and  the  difficulty  that  there  may  be  in 
palpating  foetal  parts,  mask  the  existence  of  pregnancy.     In  the  cases 


264  AFFECTIONS  OF  UTERUS. 

recorded  by  Angus  Macdonald  and  Werth,  the  nature  of  the  case  was 
clear  only  on  abdominal  section ;  Macdonald  draws  attention  to  such 
cases  as  explaining  the  phenomena  of  "  missed  labour,"  the  occurrence 
of  which  might  sometimes  give  a  clue. 

PROGNOSIS. 

Prognosis         In  prognosis  we  must  keep  in  view  the  possibility  of  ovulation  with 
ations.  °' m  menstrual  molimina,  the  secretion  of  menstrual  blood  and  its  accumula- 
tion in  a  closed  cavity,  the  probability  of  conception  and  of  gestation  in 
an  isolated  horn.     The  most  difficult  cases  are  those  in  which  the  practi- 
tioner has  to  decide  whether  marriage  is  justifiable  or  not. 

TREATMENT. 

Treatment.  Malformations  of  the  uterus  lie  beyond  the  range  of  treatment,  except 
when  they  give  rise  to  retention  of  menstrual  blood  or  of  the  products 
of  conception.  The  treatment  of  the  former  condition  will  be  considered 
under  Atresia  of  the  Vagina  (see  Section  VI.),  and  reference  will  be  made 
to  the  latter  in  the  chapter  on  Abdominal  Section.  Extirpation  of  the 
ovaries1  has  been  performed,  and  even  of  the  uterus2  or  its  detached 
horn, 3  for  dysmenorrhcea  in  cases  of  rudimentary  uterus.  Cases  of  con- 
genital atrophy,  associated  with  chlorosis,  are  amenable  to  treatment 
by  feeding-up  and  iron. 

1  By  Kleinwiichter,  Langenbeck,  Peaslee,  Savage,  Taufer  ;   2  by  Leopold  ;   3  by  Schroeder : — 
Las  Casas  dos  Santos  (op.  cit.). 


CHAPTER    XXVI. 

SMALL  OS  EXTEBNUM;    RIGIDITY,  STENOSIS,  AND 
ATBESIA  OF  CERVIX. 

LITERA  TURE. 

Barnes — Diseases  of  "Women  :  London,  1878,  p.  245.  Burton — So-called  Obstructive 
Dysmenorrhcea  :  Brit.  Med.  Jour.,  1884,  II.  607-  Chrolak — Die  Uiitersuchung  der 
weiblicheii  Genitalien  :  Billroth's  Handbuch,  Bd.  I.  S.  106.  Duke—  On  the  Rapid 
Dilatation  of  the  Cervix  Uteri  (with  discussion  at  Brit.  Med.  Ass.)  :  Brit.  Med. 
Journ.,  1888,  II.,  p.  873.  Duncan,  Matthews— On  Sterility:  Brit.  Med.  Jour., 

1883,  I.  702.     Goodell—  Rapid  Dilatation  of  the  Uterine  Canal :  Amer.  Jour.  Obstet., 

1884,  p.  1179.     Greenhalgh— Intra-uterine  Pessary  :  British  Med.  Jour.,  June  1878. 
v.  Grunewaldt — Ueber    die   Sterilitat  geschlechtskranker  Frauen  :   Archiv  f.  Gyn. 
VIII.  415.     Mackintosh — Practice  of  Physic :  London,  1836,  p.  481.     Marckwald — 
Ueber  die  kegelmantelformige  Excision  der  Vaginalportion  und  ihre  Anwendung  : 
Archiv  f.  Gyn.,  Bd.  VIII.,  S.  48.     Miillcr—'Die  Sterilitat  der  Ehe  :  Billroth's  Hand- 
buch, Bd.  I.  S.  385.     Schroedei — Krankheiten  der  weiblichen  Geschlechtsorgane : 
Leipzig,  1878,  S.  64.     Schultze — Ueber  Indication  und  Methode  der  Dilatation  des 
Uterus  :  Wiener  med.   Blatter,  1879,   Nos.  42,  43,  44,  45.     Simpson,  Sir  J.   Y.— 
Diseases   of   Women  :  Edinburgh,  1872,  p.  245.     Sims,  Marion— On  the  Surgical 
Treatment  of  Stenosis  of  the  Cervix  Uteri,  and  Discussion  :  Am.  Gyn.  Trans.,  1878, 
p.    54.     Thomas — Diseases    of    Women :    London,   1880,    p.    613.     Vedeler — Ueber 
Dysmenorrhoe :  Archiv  fiir  Gyn.,  XXI.  211.     See  Index  of  Recent  Gynecological 
Literature  in  Appendix. 

ETIOLOGY    AND    PATHOLOGY. 

THE  various  conditions  treated  of  in  this  chapter  have  been  described  Etiology 
mainly  from  clinical   observation  and  in  relation  to  the  symptoms 


FIG.  154. 

A  NORMAL  AND  A  PIN-HOLE  Os,  as  seen  in  the  SPECULUM  (Schroedcr). 

dysmenorrhoca  and  sterility.  Owing  to  the  absence  of  exact  data,  there 
has  been  room  for  great  difference  of  opinion  as  to  the  pathology  and 
frequency  of  these  conditions. 

Small  Os  Externum. — In  a  certain  number  of  cases,  6-9  p.c.  (Vedeler), 
the  os  externum  is  congenitally  smaller  than  the  normal  size ;  it  may 


266  AFFECTIONS  OF  UTERUS. 

be  so  narrow  as  to  admit  only  a  fine  probe  (pin-hole  os).  The 
contrast  between  this  and  the  normal  os  is  shown  in  fig.  154.  The 
cervix  is  conical  in  form  (fig.  155)  and  of  unusually  firm  consistence; 
sometimes  it  is  hypertrophied,  the  vaginal  portion  measuring  as 
much  as  two  inches.  The  cervical  mucous  membrane  is  frequently 
in  a  condition  of  catarrhal  inflammation  ;  according  to  Von  Griinewaldt, 
the  conical  shape  of  the  cervix  is  often  the  result  of  the  accumulation 
of  mucus. 

Rigidity  of  Cervix. — The  changes  in '  the  cervix  resulting  from  an 
increase  of  its  connective  tissue  have  been  fully  described  by  Scanzoni. 
A  peculiarly  rigid  condition  of  the  cervical  tissue,  apart  altogether  from 
any  contraction  of  the  canal,  is  observed  on  passing  bougies  in  cases  of 
dysmenorrhcea  (Matthews  Duncan).  A  similar  condition  has  been 
noted  as  specially  frequent  in  cases  of  sterility  (Olshausen,  Martin,  and 
Chrobak). 

Stenosis  (contraction)  of  the  cervical  canal  is  congenital  or  acquired. 
As  a  congenital  condition  affecting  the  cervical  canal  throughout  its 
whole  extent,  it  is  a  comparatively  rare  occurrence.  It  is  always 
associated  with  smallness  of  cervix  and  body,  pointing  to  generally 
defective  development  of  the  uterus  (which  is  further  indicated  by  the 


TIG.  155. 

CONICAL  VAGINAL  PORTION  (Barnes). 

scantiness  of  menstruation).  The  commonest  cause  of  the  acquired 
form  is  cicatrisation — after  labour,  after  amputation  of  the  cervix,  or 
after  the  repeated  application  of  strong  caustics ;  the  last  is  perhaps  the 
most  frequent.  Inflammation  of  the  mucous  membrane,  resulting  in 
adhesions,  also  produces  it. 

Atresia  of  Cervix  (d-rp^o-ts,  non-perforation),  or  occlusion  of  the  canal, 
is  rare  as  a  congenital  condition,  and  is  due  to  the  presence  of  a  cap  of 
tissue  covering  the  os  uteri.  The  canal  is  seldom,  if  ever,  imperforate 
throughout  its  course.  An  incomplete  transverse  septum  has  .been 
described  in  a  few  cases.1 

It  is  more  frequently  acquired,  and  results  from  the  following  causes  :— - 
sloughing  and  cicatrisation  after  labour ;  cicatrisation  after  the  applica- 

1  Budin— Progres  M'edical,  1887. 


STENOSIS   OF  THE  CERVIX.  267 

tion  of  caustics,  and  after  amputation  of  the  cervix ;  adhesion  of  granu- 
lations in  cervical  catarrh  (after  menopause),  and  round  the  base  of 
tumours. 

The  practical  point  for  the  practitioner  to  remember  is  that  atresia 
may  follow  the  repeated  application  of  caustics  and  amputation  of  the 
cervix.  It  occurs  also  as  part  of  the  physiological  changes  which  take 
place  after  the  menopause.  Twenty-eight  per  cent,  of  women  above 
fifty  years  of  age  have  atresia  of  the  cervix  (Hennig). 

SYMPTOMS   AND    DIAGNOSIS. 

The  symptoms  found  most  frequently  associated  with  these  conditions  Symptoms, 
are — 

Dysmenorrhoea, 
Sterility. 

We  say  'associated,'  because  the  relation  of  the  symptoms  to  the 
pathological  condition  is  as  yet  not  known.  There  is  no  subject  in 
Gynecology  round  which  more  discussion  has  raged,  and  concerning 
which  there  are  at  present  more  abrupt  differences  of  opinion. 

Dysmenorrhcea. — Mackintosh,  from  a  doubtful  analogy  between  the 
menstruating  uterus  and  the  bladder,  introduced  dilatation  with  bougies 
as  a  treatment  of  dysmenorrhoea.  The  theory  was  that  a  stricture  pre- 
vented the  discharge  of  blood  in  the  former  case,  just  as  it  prevents  a 
discharge  of  urine  in  the  latter  •  and  that  the  pain  was  due  to  uterine 
efforts  to  overcome  obstruction.  Sir  James  Simpson  showed  that  stenosis 
could  not  be  the  only  factor,  since  obstructive  dysmenorrhoea  might  be 
equally  present  with  a  patulous  cervix ;  it  depended  also  on  the  amount 
of  the  menstrual  discharge  and  the  danger  of  its  clotting  while  in  the 
uterus,  and  may  be  absent  where  though  the  os  is  small  the  flow  is 
scanty.  Marion  Sims  took  up  the  position  that  painful  menstruation 
was  almost  wholly  due  to  mechanical  causes,  and  was  the  great  exponent 
of  what  is  known  as  'the  mechanical  theory.'  Thomas,  Barnes,  Schroeder 
and  De  Sinety  all  accept  this  theory,  more  or  less,  in  their  handbooks  of 
Gynecology.  On  the  other  hand,  Matthews  Duncan,  in  his  recent 
lectures  on  Sterility,  says  he  has  never  seen  a  pin-hole  os  in  cases  of 
dysmenorrhoea ;  and  attributes  the  pain  to  irregular  contractions  of  the 
uterus  which  have  nothing  to  do  with  expulsion  of  its  contents. 
Vedeler's  recent  investigations  have  shown  that  a  small  os  externum  is 
as  common  in  patients  without  as  in  those  with  dysmenorrhoea.  Emmet, 
at  the  discussion  on  Sims'  Operation  before  the  American  Gynecological 
Society,  characterised  the  mechanical  theory  of  dysmenorrhoea  as  a  myth  ; 
in  his  Gynecology,  he  says  that,  unless  the  flow  is  scanty,  painful 
menstruation  is  accompanied  by  clots  but  that  their  formation  does  not 
depend  upon  obstruction. 

Hitherto,  conclusions  have  been  drawn  almost  entirely  from  the  con- 


268  AFFECTIONS  OF   UTERUS. 

dition  of  the  uterus  and  cervix  between  the  menstrual  periods ;  and  it 
will  be  evident  from  the  foregoing  how  wide  is  the  difference  of  opinion 
on  the  subject.  It  seems  to  us  that  valid  conclusions  can  only  be 
drawn  from  the  condition  of  the  cervix  during  menstruation,  and  that 
the  diversity  of  opinion  will  remain  until  we  have  accurate  knowledge 
on  this  point. 

We  have  called  the  condition  "Small  Os  Externum"  instead  of 
"Stenosis"  advisedly;  as  the  latter  word  implies  that  there  is  resistance 
to  the  outflow  of  blood,  while  the  as  yet  scanty  evidence  rather  seems 
to  show  that  the  canal  becomes  more  patulous  during  menstruation 
than  at  any  other  time. 

Relation  of  Sterility. — When  we  come  to  treat  of  sterility,  we  shall  find  that  it  is 
Sterility.  °  frequently  associated  with  dysmenorrhoea.  According  to  the  statistics 
given  by  Matthews  Duncan,  as  well  as  those  by  Marion  Sims  and  Emmet, 
about  one-half  of  cases  of  sterility  suffer  from  severe  dysmenorrhcea ; 
and  two-thirds  of  Vedeler's  cases  of  dysmenorrhoea  in  married  women 
were  sterile.  A  narrow  os  externum,  according  to  the  mechanical  theory, 
hinders  the  upward  passage  of  the  spermatozoa  just  as  it  retards  the 
downward  flow  of  the  menstrual  blood.  This  explanation  is  evidently 
open  to  the  criticism  that  the  spermatozoa  are  microscopic ;  and  that, 
as  Fritsch  puts  it,  a  drop  of  water  will  fall  as  easily  through  a  ring  of  2 
cm.  diameter  as  through  a  hoop  of  100.  It  is,  however,  quite  possible 
that  a  narrow  os  externum  while  not  absolutely  preventing  conception 
may  retard  it :  Miiller,  in  enforcing  the  very  important  distinction 
between  absolute  and  relative  sterility,  thinks  that  a  contracted  os  may 
render  conception  more  difficult,  especially  where  the  spermatozoa  are 
scanty  in  the  spermatic  fluid.  Thus,  a  counter-illustration  to  Fritsch's 
would  be  that  where  the  drops  are  few  there  is  more  chance  of  catching 
them  in  a  bowl  than  in  a  thimble.  Although  there  is  a  general  reaction 
against  stenosis  per  se  as  a  cause  of  sterility,  yet  the  associated  cervical 
catarrh  is  considered  by  the  majority  to  play  an  important  role  through 
stagnation  of  the  mucous  secretion.  It  has  not,  however,  been  proved 
that  a  plug  of  mucus  can  be  an  effectual  bar  to  the  progress  of 
spermatozoa,  and  catarrh  is  a  very  frequent  condition  in  parous 
women. 

A  rigid  condition  of  the  cervix  has,  as  already  said,  been  frequently 
noted  as  present  in  cases  of  sterility.  Matthews  Duncan  suggests  that 
it  operates  through  checking  spontaneous  dilatation  of  the  cervix  during 
coition. 

In  studying  the  complex  question  of  sterility  (v.  Section  IX.),  the  at 
first  too  obvious  mechanical  causes  sink  into  insignificance  as  soon  as  we 
come  in  sight  of  the  less  obtrusive  and  more  subtle  physiological  and 
vital  considerations ;  and,  after  a  careful  survey  of  the  literature,  we 
come  to  the  conclusion  that  any  discussion  of  sterility  in  which 


STENOSIS  OF  THE   CERVIX.  269 

mechanical  considerations  have  a  prominent  place  must  be  inadequate 
and  will  always  be  bootless. 

DIAGNOSIS. 

A  history  of  dysrnenorrhcea  and  sterility  will  lead  us  to  suspect  that  Diagnosis 
one  of  [these    conditions  of  the    cervix  may  be  present.     On  vaginal  °f  Stenosis 
examination,  the  finger  recognises  the  conical  shape  and  firm  consistence  Cervix, 
of  the  cervix.     In  cases  of  small  os  externum,  the  first  impression  is  that 
it  is  altogether  absent ;  but  more  careful  examination  detects  a  slight 
depression.     The  speculum  shows  the  appearance  represented  in  figs.  1 54 
and  155.     The  sound  is  passed  with  difficulty  :  but  we  must  remember 
that  difficulty  in  passing  the  sound  is  quite  unreliable  as  a  test  of  the 
canal's  being  relatively  narrower  at  a  given  point ;  a  sharp  flexion,  a 
projecting  tumour  or  even  a  fold  of  mucous  membrane  may  arrest  the 
sound.      Burton  by  passing  the   sound  in  six  cases  of  dysmenorrhoea 
during  the  height  of  the  pain  made  the  interesting  observation  that  the 
canal  was  more  patent  then  than  at  any  other  period. 

PROGNOSIS. 

This  must  always  be  guarded,  as  the  etiological  relationship  between  Prognosis, 
the  conditions  of  the  cervix  described  and  these  symptoms  is  still  sub 
lite,    and    the   results    of    our    empirical    treatment    correspondingly 
uncertain. 

TREATMENT. 

The  methods  of  treatment  are — 

A.  Dilatation, 

B.  Division. 

Dilatation  for  stenosis  is  carried  out  by  passing  graduated  bougies, 
by  sponge  or  laminaria  tents,  by  forcible  dilatation  with  instruments. 
Division  is  effected  by  the  metrotome  or  by  scissors.  We  here  consider 
only  dilatation  for  stenosis  ;  its  use  for  intra-uterine  medication  will  be 
dealt  with  under  the  treatment  of  Endometritis. 

A.  Dilatation. 

Sponge  and  laminaria  tents  were  formerly  used,  but  are  now  abandoned  Treatment 
because  of  the  dangers  of  septicaemia;  at  a  recent  discussion  in  the£ y  8 

British  Medical  Association  (1888)  the  consensus  of  opinion  was  entirely  tion. 
in  favour  of  rapid  dilatation,  or  division,  as  against  the  use  of  tents. 

Dilatation  by  means  of  graduated  bougies  was  brought  into  prominent 
notice  by  Mackintosh,  who  employed  straight  metallic  bougies  of 
different  degrees  of  thickness.  He  passed  first  a  small  one  not  thicker 
than  a  probe,  and  then  larger  ones  till  the  os  was  rendered  quite  patulous. 
This  mode  of  treatment  is  specially  recommended  by  Matthews  Duncan. 


270 


AFFECTIONS  OF  UTERUS. 


A  No.  9  bougie  is  the  largest  size  which  will  pass  through  a  virgin  cervix. 
We  have,  therefore,  to  begin  with  one  of  smaller  calibre,  say  6  or  7,  and 
go  up  to  a  No.  11  or  12,  as  the  cervix  must  be  over-distended  to  effect  a 
cure.  The  successive  numbers  are  passed  at  various  sittings  and  not  on 
the  same  day ;  so  that  the  whole  treatment  requires  about  a  week. 
Hegar's  dilators  (seep.  131)  are  also  used  in  stenosis. 

Various  dilators  with  expanding  blades  have  been  devised.  Fig.  156 
shows  the  form  used  by  Schultze.  He  dilates  the  cervical  canal  before- 
hand with  laminaria ;  he  then  washes  it  out  with  a  2  per  cent,  solution 


FIG.  156. 
SCHULTZE'S  DILATOR. 

of  carbolic  acid,  as  he  attributes  many  of  the  serious  consequences  of 
forcible  dilatation  and  incision  to  the  absorption  of  the  secretions.  The 
dilator  is  now  introduced,  and  the  blades  (which  open  antero-posteriorly) 
are  forcibly  separated.  Ellinger  has  made  a  dilator  so  constructed  that 
the  blades  remain  parallel  to  one  another  while  being  separated  ;  Goodell 
has  had  very  good  results  from  forcible  dilation  with  this  instrument 
both  with  regard  to  Dysmenorrhcea  and  Sterility.  The  dilator  em- 


FIG.  157. 

MAKION  SIMS'  DILATOR  (Sims). 

ployed  by  Marion  Sims  is  seen  at  fig.  157.      Other  forms  have  been 
recently  introduced  by  Reid,  Duke,  and  More  Madden.1 

B.  Division. 

Treatment  Division  of  the  cervix  with  the  knife  was  introduced  by  Sir  James  Y. 
by  DM°S1S  SimPson-  The  instrument  which  he  devised  for  this  purpose  was  the 
sion.  metrotome  represented  at  fig.  158. 

1  See  under  "  Instruments '  in  Index  of  Recent  Gynecological  Literature  in  Appendix. 


STENOSIS   OF  THE   CERVIX. 


271 


It  is  a  bistoury  cache,  with  a  single  blade  sharp  on  the  outer  edge  Sir  James 
which  is  unsheathed  on  compressing  the  handle.     The  screw  on  the  Metro- 
handle  regulates  the  extent  to  which  the  blade  is  to  be  protruded.  tome- 


FIG.  158. 

Sir  JAMES  SIMPSON'S  METROTOME  (Sir  J.  Y.  Simpson),    a  shows  position  of  blade  when  protruded. 

The  instrument  was  passed  in  till  the  point  almost  -reached  the  os  internum  ;  it  was 
turned  with  the  blade  to  one  side,  and  then  withdrawn,  the  handle  being  at  the  same 
time  more  and  more  compressed.  The  result  was  a  lateral  incision  in  the  cervix,  super- 
ficial at  its  upper  extremity  but  becoming  deeper  as  it  passed  downwards  till  at  its  base 
it  completely  divided  the  vaginal  portion.  The  instrument  was  re-introduced  and  a 


FIG.  159. 
NULLIPAROUS  Os  UTERI  (Sir  J.  Y.  Simpson). 

similar  incision  made  on  the  opposite  side.  The  result  of  this  operation  was  that  the 
narrow  circular  os  became  an  orifice  with  gaping  lips.  As  Sir  J.  Y.  Simpson  points  out, 
the  nulliparous  os  is  thus  made  to  resemble  in  form  the  os  of  a  uterus  which  has  been 
pregnant ;  that  is  instead  of  being  circular  and  small,  it  is  made  transverse  and  gaping 
(cf.  figs.  159  and  160).  That  a  patulous  condition  of  the  os  and  cervical  canal  greatly 
favours  fertilisation  is  proved  by  the  readiness  with  which  conception  follows  abortion. 


FIG.  160. 
PAROUS  Os  UTERI  (Sir  J.  Y.  Simpson) 

Other  forms  of  nietrotome  have  been  introduced  by  Coghill,  Greenhalgh, 
Savage,  and  Routh.  Those  of  Greenhalgh  and  Savage  are  double-bladed, 
while  that  of  Routh  has  the  blades  curved. 


272  AFFECTIONS  OF  UTERUS. 

We  are  indebted  to  Marion  Sims  for  substituting  the  scissors  for  the 
metrotome.  The  objections  to  the  latter  instrument  are  that  we  do  not 
know  how  deep  the  incision  is  being  made,  nor  whether  both  incisions 
are  being  made  equally.  The  practitioner  will  find  the  scissors  easier  to 
handle  than  the  knife.  A  pair  of  ordinary  strong  scissors  will  do, 
provided  they  are  sharp  and  the  cervix  be  firmly  held  with  the  volsella. 


FIG.  161. 

SHOWING  THE  BILATERAL  DIVISION  OF  THE  CERVIX,  with  Kuchenmeister's  Scissors  (Barnes). 

The  scissors  of  Kuchenmeister  (fig.  103)  and  Hart  (fig.  104)  have  this 
advantage,  that  the  hook  on  the  external  blade  prevents  the  cervix  from 
slipping  out  as  the  section  is  being  made. 

Operation  The  operation  is  performed  as  follows.  The  patient  is  placed  semiprone. 
ral  Divi-6  ^ne  Sims  speculum  is  passed,  and  held  by  an  assistant.  This  operation, 
sion  of  as  indeed  all  operations  on  the  cervix  or  vagina,  should  be  performed 
under  continual  irrigation  from  a  vaginal  douche.  If  the  irrigation  be 
not  employed,  the  vagina  should  be  thoroughly  syringed  beforehand 
with  1  to  40  carbolic  acid  solution.  The  anterior  lip  of  the  cervix  is 
laid  hold  of  with  the  volsella ;  the  scissors  are  introduced,  the  straight 
blade  being  passed  within  the  cervical  canal ;  the  point  or  hook  of  the 
external  blade  is  carried  to  about  one-third  up  the  vaginal  portion  of 
the  cervix  (see  fig.  161)  and  the  section  made.  In  many  cases,  all  that 
is  necessary  is  to  divide  the  ring  round  the  os  extern  um ;  when  this  is 


FIG.  162. 
GLASS  PLUG  TO  KEEP  THE  CERVIX  PATULOUS  AFTER  DIVISION  (Thomas). 

divided  the  cervical  canal  is  sometimes  found  to  be  dilated  above  it. 
Should  haemorrhage  occur,  some  perchloride  of  iron  is  swabbed  on  the 
cut  surface  and  a  vaginal  tampon  of  lint  soaked  in  an  antiseptic  is 
applied. 

One  result  of  Emmet's  work  on  laceration  of  the  cervix  has  been  to 
draw  the  attention  of  gynecologists  to  the  fact  that  ectropion  of  the 
mucous  membrane  and  secondary  cervical  catarrh  may  follow  artificial 


STENOSIS  OF  THE   CERVIX.  273 

division  of  the  vaginal  portion  of  the  cervix.  When  this  operation  is 
necessary,  we  recommend,  therefore,  that  it  be  done  by  three  or  four 
shallow  notches  round  the  margins  of  the  os  externum.  As  will  be 
evident  from  what  has  been  said  under  Symptoms,  the  scope  of  this 
operation  is  very  limited  imless  we  have  recourse  to  it  as  a  stage  in 
treating  cervical  catarrh  in  a  nullipara.  We  have  described  it  min- 
utely as  the  practitioner  is  more  apt  to  be  careless  in  minor  operations. 

More  important  than  the  incision  is  the  after-treatment.     The  patient  Treatment 
must  be  seen  on  the  following  day,  and  every  second  day  for  a  fortnight, 


and  the  finger  passed  in  on  each  occasion  to  prevent  union  of  the  cut  Division  of 
surfaces  and  dilate  the  cervical  canal.     To  keep  the  canal  open,  Thomas 
recommends  the  use  of  a  glass  cervical  plug  (fig.  162)  kept  in  position 
by  a  solid  plate  of  the  form  of  an  Albert  Smith  pessary.     Duke  uses  a 
spiral  wire  stem  to  keep  the  canal  patulous  after  dilatation. 


FIG.  163. 

CONICAL  EXCISION  OF  CERVIX.     The  figure  to  the  left  (a)  shows  the  flaps  and  position  of  sutures ;  that 
to  the  right  (6),  the  appearance  of  the  os  after  the  sutures  are  tied. 

Excision  of  a  portion  of  the  cervix  is  also  done  with  a  view  to  convert 
the  stenosed  into  a  gaping  os  like  that  of  a  multipara  (v.  fig.  160).  It  is 
a  favourite  operation  in  Germany,  was  introduced  by  Simon  and  elaborated 
by  Marckwald,  and  is  known  as  the  "  kegelmantelformige "  ("  cone- 
mantle-like,"  from  the  shape  of  the  piece  cut  out)  excision.  The  cervix  is 
split  into  an  anterior  and  a  posterior  lip,  and  a  wedge-shaped  piece  cut 
out  of  each  so  that  the  cervix  seen  from  the  front  has  the  appearance 
of  fig.  163  a,  while  from  the  side  it  looks  like  fig.  168.  The  lips  are 
then  stitched  separately — cervical  mucous  membrane  being  united  to 
vaginal  (fig.  1636).  We  shall  have  to  refer  to  this  operation  again  in 
Chap.  XXVIII. 

Atresia  of  the  cervix  is  chiefly  of  importance  in  regard  to  the  accumula-  Treatment 
tion  of  menstrual  blood  or  mucus  above  the  obstruction.     It  is  thisof  Atresia- 
which  produces  the  Symptoms  and  calls  for  Treatment.      It  will  be 
better  to  defer  the  consideration  of  these  till  we  treat  of  Atresia  Vaginae 
(Section  VI.). 


CHAPTER    XXVII. 

ATROPHY  OP  THE  CERVIX  AND  UTERUS: 
SUPERINVOLUTION. 

Conditions  \yE  meet  with  an  atrophic  condition  of  the  cervix  and  uterus  under 

which        four  different  conditions  : — 

Atrophy 

of  Uterus  1.  As  a  congenital  condition ; 

2.  Associated  with  certain  constitutional  affections,  as  phthisis, 

scrofula,  chlorosis ; 

3.  In  the  puerperal  uterus,  as  the  result  of  superinvolution  ; 

4.  After  the  menopause. 

Should  the  student  find  on  vaginal  examination  that  the  cervix  is 
small  and  projecting  only  slightly  into  the  vagina,  and  on  bimanual 
examination  that  the  body  of  the  uterus  is  found  with  difficulty  and  is 
smaller  than  it  should  be,  he  must  next  ascertain  which  of  the  above- 
mentioned  causes  has  produced  the  atrophy. 

The  history  will  enable  him  to  form  his  diagnosis.  With  the  congenital 
condition  there  is  a  history  of  amenorrhoea  or  scanty  menstruation  since 
puberty,  of  sterility  if  the  patient  has  entered  married  life,  and  of  hysteria 
and  other  disturbances  of  the  nervous  system  which  usually  accompany 
imperfect  development  of  the  uterus.  The  constitutional  condition,  and 
especially  the  state  of  the  blood  and  of  the  lungs,  in  other  cases  enables 
him  to  account  for  the  condition  of  the  uterus.  Probably  the  small 
uterus  found  in  chlorotic  patients  is  a  congenital  condition,  and  not 
secondary  to  the  constitutional  state.  If  the  atrophic  condition  be  the 
result  of  superinvolution,  there  is  a  history  of  childbirth  or  abortion  with 
non-appearance  of  menstruation  after  it.  With  regard  to  the  meno- 
pause, the  age  of  the  patient  is  the  chief  guide ;  we  must  remember 
the  possibility  of  an  early  menopause,  as  early  as  at  the  age  of 
thirty-five. 

The  only  atrophic  condition  which  we  shall  consider  here  is  that 
occurring  in  the  puerperal  uterus  as  the  result  of  superinvolution.  To 
Sir  James  Simpson's  description  of  this  condition  we  are  chiefly 
indebted. 


SUPERINVOLUTION  OF  THE   UTERUS.  275 

STJPERINVOLUTION  OP  THE  UTERUS. 

LITERATURE.  Frommel — Ueber  puerperale  Atrophie  des  Uterus  :  Zeits.  f.  Geburts.  und 
Gynak.,  Bd.  vii.,  H.  ii.,  S.  305.  Jaquet — Ueber  Atrophia  Uteri :  Berl.  Beitrage  zur 
Geburts.  und  Gynak.,  Bd.  ii.,  S.  3.  Johnson,  T.  J. — Superinvolution  of  the  Uterus 
Am.  Gyn.  Trans.,  1883,  p.  1064.  Klob — Patholog.  Anatom.  der  weib.  Sexualorgane  : 
"VVien,  1864,  S.  205.  Simpson,  A.  R. — Superinvolution  of  the  Uterus :  Edin.  Med. 
Jour. ,  May  1883  (in  which  the  literature  is  given  to  date).  Simpson,  Sir  J.  Y.  — Morbid 
Deficiency  and  Excess  in  the  Uterus  after  delivery  :  Selected  Obstetrical  and  Gyne- 
cological Works,  1871,  p.  595.  On  Superinvolution  of  the  Uterus  and  Amenorrhosa  : 
Diseases  of  Women,  Edin.,  1872,  p.  597. 

PATHOLOGY. 

The  uterus  is  small.  Its  external  length  may  be  reduced  from  the 
normal  3  to  If  inches.  The  walls  are  thin  and  flaccid,  sometimes  of  a 
dense  and  fibrous  consistence.  The  vaginal  portion  projects  only  slightly 
into  the  vagina,  and  may  be  almost  flush  with  the  vaginal  roof.  The  os 
may  be  relatively  patulous,  or  contracted  so  as  only  to  admit  a  probe. 
The  uterine  cavity  is  reduced  to  2i,  2,  or  even  Ii  inches  in  length.  The 
ovaries  are  atrophied,  and  sometimes  show  an  increase  of  fibrous  tissue 
in  their  structure.  The  accompanying  specimen  (fig.  164),  described  by 
Sir  James  Simpson,  illustrates  these  points. 

ETIOLOGY. 

As  to  the  frequency  of  this  condition,  A.  R.  Simpson  found  it  present 
in  22  out  of  1300  cases,  that  is  in  about  1-7  per  cent. ;  Frommel  estimates 
its  frequency  at  1  per  cent.  The  reason  why,  in  certain  cases,  the  pro- 
cess of  involution  during  the  puerperium  goes  on  till  the  uterine  cavity 
is  reduced  to  less  than  2i  inches  in  length  is  not  known.  A  condition 
of  transitory  Superinvolution — in  which  the  superinvoluted  uterus  returns 
to  the  normal  length  again — has  been  observed.  Protracted  Lactation 
seems  the  most  important  cause  (Frommel).  We  have  seen  this  in  two 
cases,  and  Chiari  has  also  drawn  attention  to  it.  In  some  instances  there 
is  a  history  of  great  loss  of  blood  at  the  confinement ;  A.  R.  Simpson 
found  this  in  10  out  of  his  22  cases,  and  in  a  case  of  this,  reported  by 
Whitehead, *  the  atrophic  changes  had  progressed  so  far  that  no  trace  of 
a  uterus  was  found  on  the  most  careful  examination.  In  other  instances 
pelvic  peritonitis  has  occurred  during  the  puerperium  :  this  can  produce, 
we  know,  atrophy  of  the  ovary  through  binding  it  down  with  adhesions ; 
and  atrophy  of  the  ovaries  may  lead  to  atrophy  of  the  uterus.  It  is  also 
associated  with  the  tubercular  diathesis  (Klob). 

The  term  Superinvolution  has  also  been  applied  to  atrophy  of  the 
uterus  following  hypertrophy  from  causes  other  than  pregnancy,  e.g.  sub- 
mucous  fibroids,  and  that  following  operations  on  the  cervix,2  but  it 
is  best  to  limit  it  to  cases  of  atrophy  after  parturition. 

1  British  Med.  Jour.,  Oct.  1872. 

2  Harden  describes  it  as  following  Emmet's  operation  :  AM.  Joum.  of  Obslet.,  1888,  p.  1018. 


SUPERINVOLUTIOX  OF  THE   UTERUS.  Ill 


SYMPTOMS. 

Continued  amenorrhoea  is  the  symptom  which  leads  the  patient  to  seek 
advice.  After  she  has  ceased  nursing,  she  expects  the  flow  to  return. 
It  does  not  do  so,  however,  even  after  months  have  passed.  Pain  in  the 
back,  weakness,  and  hysterical  symptoms  are  sometimes  present. 

DIAGNOSIS. 

The  small  cervix  at  once  suggests  what  the  condition  is.  We  some- 
times have  difficulty  in  making  out  the  uterus  bimanually ;  here  the 
examination  per  rectum,  combined  with  the  volsella,  is  useful.  The  best 
idea  of  the  size  of  the  uterus  is  gained  by  pressing  the  ball  of  the 
finger  in  the  rectum  against  the  isthmus  of  the  uterus,  and  then 
moving  the  uterus  upwards  and  downwards  upon  the  finger  which  can 
thus  estimate  accurately  its  size ;  having  done  this,  we  make  more 
traction  on  the  uterus  to  bring  it  as  far  down  as  possible,  and  examine 
the  ovaries. 

The  sound  must  be  used  with  care,  as  it  easily  perforates  the  thin 
walls  of  the  uterus.  It  does  not  pass  into  the  uterus  as  far  as  the 
2^  in.  knob. 

Differential  diagnosis  must  be  made  from — 

Congenital  malformation ; 
Congenital  atrophy ; 
Senile  atrophy. 

PROGNOSIS. 

This  should  always  be  guarded.  The  curability  of  the  case  depends, 
as  Fordyce  Barker  has  pointed  out,  011  the  condition  of  the  Ovaries— a 
point,  however,  exceedingly  difficult  to  determine.  When  the  patient 
has  the  menstrual  molimina  and  the  menstruation  though  scanty  still 
persists,  we  may  hope  for  improvement  even  though  the  uterus  is  small. 

TREATMENT. 

From  the  unsatisfactoriness  of  treatment,  such  cases  may,  as  a  rule, 
be  left  alone.  Iron  and  other  constitutional  remedies  may  be  tried. 
When  local  treatment  is  called  for,  this  consists  in  stimulating  the 
uterus  to  hypertrophy  by  placing  a  foreign  body  in  its  cavity. 

The  galvanic  intra-uterine  stem  pessary  of  Sir  James  Simpson  was  devised  for  this  Mode  of 
purpose.     The  stem  is  made  in  its  upper  half  of  zinc,  in  its  lower  half  of  copper ;  the  bulb  Introduc- 
is  also  of  copper.     The  stem  should  always  be  shorter  than  the  uterine  cavity  by  a  |  of  lnS  Intra- 
an  inch ;  otherwise  it  may  perforate  the   fundus.     It   is   introduced  as  follows.     The 
cervix  is  laid  hold  of  with  the  volsella  to  draw  it  towards  the  vaginal  orifice  and  to  steady 
it.     The  stem  is  held  with  the  bulb  between  the  finger  and  thumb,  and  passed  into  the 


278  AFFECTIONS  OF  UTERUS. 

cervix  for  about  an  inch.     If  the  vaginal  orifice  be  too  narrow  to  allow  of  this  manipula- 
tion, the  bulb  is  fixed  on  the  end  of  a  staff  and  thus  carried  in. 

A  glycerine  plug  is  passed  to  keep  the  stem  in  position  at  first.  The  patient  should 
keep  at  rest  for  one  day  after  the  stem  has  been  introduced,  and  should  be  instructed  to 
send  at  once  if  pain  is  felt  in  the  pelvis  ;  we  have  seen  pelvic  inflammation  follow  the 
introduction  of  a  stem  pessary. 

Galvanism  has  also  been  used. 


CHAPTER    XXVIII. 

HYPERTROPHY  OF  THE  CERVIX:  AMPUTATION. 

LITERATURE. 

Byrne — Amputation  and  Excision  of  the  Cervix  Uteri :  Trans.  Americ.  Gyn.  Soc.,  Boston, 
II.  pp.  57  and  110.  Galabin— Lond.  Obst.  Journ.,  Sept.  1878.  Goodell— Clinical 
Notes  on  the  Elongations  of  the  Cervix  Uteri :  Am.  Gyn.  Trans.,  1880,  p.  268. 
Hegar  und  Ealteribach — Operative  Gynakologie  :  Stuttgart,  1881,  S.  445.  Huguier 
— Meraoires  sur  les  Allongements  Hypertrophiques  du  Col  de  1'Uterus  :  Paris,  1860. 
Leblond — Operative  Gynecologic  :  Paris,  1878.  Marckicald — Ueber  die  kegelmantel- 
formige  Excision  der  Vaginal  portion,  etc. :  Archiv  f.  Gyn.  Bd.  viii.'  S.  48.  Milller 
—Die  Amputatio  Colli  Uteri :  Zeitschrift  fiir  Geburt.  und  Gyn.  Bd.  ix.  S.  178. 
Schroeder — Charite-Annalen,  1878.  Zur  Technik  d.  plast.  op.  am  cervix  uteri : 
Zeitschrift  fiir  Geburt.  u.  Gyn.,  Bd.  iii.  S.  419 ;  Bd.  ,vi.  Hft.  2,  S.  218.  Simon 
— Monatsch.  f.  Geburtskunde,  xiii.  S.  418.  Sims,  Marion — Uterine  Surgery,  1866. 
Stratz — Ueber  einseitige  Hypertrophie  des  untern  Cervicalabschnitts  :  Zeits.  fiir  Geb. 
und  Gyn.,  Bd.  XII.,  S.  229.  See  also  Index  of  Recent  Gynecological  Literature  in 
the  Appendix. 

HYPERTROPHY  of  the  whole  uterus  occurs  in  two  forms : — 

1.  Hypertrophy  of  the  muscular  tissue — in  pregnancy ; 

2.  Hypertrophy  of  the  connective  tissue — in  subinvolution  and 

chronic  metritis,  both  of  which  will  be  considered  under 
Chronic  Metritis  (Chap.  XXXII.). 
Hypertrophy  of  the  cervix  alone  calls  for  special  notice  here. 

HYPERTROPHY  OF  THE  CERVIX. 
Under  this  head  we  consider  two  conditions  : — 

A.  Hypertrophy  limited  to  the  vaginal  portion,  which  is  a  distinct 

primary  lesion ; 

B.  Hypertrophy  of    the    supra-vaginal   portion,    which    is    usually 

associated  with  hypertrophy  of  the  body  of  the  uterus;  this 
occurs  in  prolapsus  uteri  and  is  probably  secondary  to  that 
condition. 

A.    HYPERTROPHY    OF    THE    VAGINAL    PORTION. 

Pathology. — The  characteristic  of  this  condition  of  the  cervix  is  a  great  Hyper- 
increase  in  length  affecting  it  equally  all  round  1  (fig.  166).     The  mucous  Vaginal0 
membrane   and  the  subjacent  tissue  are  not   thickened,   so    that  the  Portion. 

*  Only  one  case  of  unilateral  hypertrophy  in  a  nullipara  could  be  found  by  Stratz  in  the  literature 
—  a  case  recorded  by  Huguier.  Partial  hypertrophies  are  less  rare  in  multipart  and  will  be  referred 
to  under  Laceration  of  the  Cervix. 


280 


AFFECTIONS  OF  UTERUS. 


diameter  of  the  cervix  is  not  much  increased.  As  the  result  of  the 
increase  in  length,  the  conical  apex  of  the  cervix  comes  to  lie  immediately 
behind  the  hymen  and  may  protrude  through  the  vaginal  orifice  (fig.  165). 
The  os  externum  is  often  small. 

Etiology. — This  condition  is  a  true  hypertrophic  growth ;  it  is  not 
very  common  and  the  cause  of  it  is  unknown.  As  it  occurs  in  the 
virgin,  it  is  probably  congenital.  Sometimes  it  does  not  attract  atten- 
tion till  the  patient  enters  married  life,  when  it  produces  as  a  rule 
sterility  because  the  form  of  the  cervix  interferes  with  conception. 

The  cervix  is  frequently  thickened  as  the  result  of  chronic  inflamma- 
tion consequent  on  its  laceration  in  childbirth  ;  this  is  not  a  true 


FIG.  165. 

HYPERTROPHIED  VAGINAL  PORTION  c  PROTRUDING  THROUGH  THE  VULVA.    The  Sound  has  passed 
very  far  into  the  small  os  o  (Schroeder). 

hypertrophic  growth,  and  will  be  considered  under  Laceration  of  the 
Cervix  (Chap.  XXIX.). 

Symptoms. — The  symptoms  are  due  to  the  presence  of  the  hypertro- 
phied  cervix  in  the  vagina.  There  is  bearing-down  as  in  prolapsus 
uteri,  irritation  of  the  mucous  membrane  of  the  vagina  and  consequent 
leucorrhoea,  discomfort  on  walking  about  and  on  rising  suddenly.  If 
the  cervix  protrude  beyond  the  vulva,  ulceratiou  of  its  mucous  membrane 
and  excoriation  are  produced. 

Diagnosis.— This  presents  no  difficulty.      The  fornices  are  found  in 


AMPUTATION  OF  THE  CERVIX.  281 

their  normal  position  on  vaginal  examination  (see  fig.  166),  the  fundus 
uteri  at  its  normal  height  in  the  pelvis  on  bimanual  examination. 
These  two  clinical  facts  indicate  that  the  law  position  of  the  apex  of  the 
cervix  is  not  due  to  a  descent  of  the  fundus  but  to  a  hypertrophy  of  the 
cervix,  and  that  the  hypertrophy  of  the  cervix  is  limited  to  the  portion 
which  projects  into  the  vagina  (cf.  fig.  166  with  fig.  174  and  fig.  175). 
The  sound  may  pass  five  inches  or  more  into  the  cervical  canal ;  as  the 
patient  is  usually  a  nullipara  and  the  abdominal  walls  therefore  firm,  it 
facilitates  the  Bimanual  to  do  it  with  the  sound  in  the  uterus.  The 
combined  recto-vaginal  examination  shows  that  the  uterus,  above  the 
vagina,  is  of  normal  length. 


FIG.  100. 

HYPERTROPHY  OF  VAGINAL  PORTION  OF  CERVIX.     Neither  fornix  is  obliterated  (Schroeder). 
Section  of  Pelvis  seen  in  fig.  165. 

Treatment. — This  consists  in  amputation  of  the  cervix  which  is  the 
only  course  open  to  us,  because  the  hypertrophy  will  not  diminish  but 
rather  increase.  Amputation  is  performed  by  three  methods  : — 

1.  Scissors  or  knife, 

2.  Ecraseur, 

3.  Galvano-caustic  wire. 

The  successive  improvements  in  the  method  of  amputation  with  the 
knife  may  be  thus  tabulated  ;  by  Marion  Sims  was  made  the  advance 
of  covering  the  stump  with  mucous  membrane. 

(1.)   Old  method.     Circular  amputation;  rawr  surface  touched  with 

caustic  or  cautery  ;  healing  by  granulation. 

(2.)  Sims'  method.  Circular  amputation ;  vaginal  mucous  mem- 
brane stitched  to  vaginal  mucous  membrane ;  healing 
partly  by  first  intention  (fig.  167). 


282 


AFFECTIONS  OF  UTERUS. 


(3.)  Hegar's  method.  Circular  amputation  ;  vaginal  mucous  mem- 
brane stitched  to  mucous  membrane  lining  cervix  (figs. 
170  and  172) ;  healing  by  first  intention. 

(4.)  Simon  and  Marckwald.  Flap  amputation  by  wedge-shaped 
excision  of  lips  separately  (figs.  163  and  168);  vaginal 
mucous  membrane  stitched  to  that  lining  cervix  on  each 
lip  (fig.  170) ;  healing  by  first  intention. 

The  supra-vaginal  amputation  will  be  considered  under  operations  for 
cancer  of  the  cervix. 

The  best  method  of  performing  the  amputation  is  to  split  the  cervix 
by  a  transverse  incision  into  an  interior  and  posterior  lip ;  then  ampu- 
tate each  lip  separately  making  the  line  of  amputation  wedge-shaped ; 
finally  bring  together  the  projecting  flaps  of  vaginal  and  cervical  mucous 
membrane  with  wire  sutures. 


FIG.  107. 

SIMS'  METHOD  OP  PASSING  THE  SUTURES.     Vaginal  mucous  membrane  stitched  to  vaginal  (Sims). 

Amputa-         The  operation.     The  instruments  required  are  the  following  : — 
tion  of  the 

Cervix  for  Antiseptic  douche,  Bistouries, 

Sims'  speculum,  Dissecting  forceps, 

Spatulse,  Blunt  hook, 

Volsellse,  Scissors, 

Straight  needles  fixed  on  Artery  forceps, 

handles,  Small  curved  needles  and  needle 
Silver  wire,  holder. 


Simple  Hy- 
pertrophy. 


A.  R.  Simpson  operates  as  follows.  The  patient  is  placed  in  the 
lithotomy  posture.  Continued  irrigation  with  a  2  p.c.  solution  of 
carbolic  is  employed.  The  cervix  is  drawn  down  with  volsella.  An 
india-rubber  ring  may  be  passed  over  the  volsella  on  to  the  cervix  and 
placed  so  as  to  constrict  the  cervix  just  below  the  fornices  (fig.  169)  to 
control  haemorrhage.  The  cervix  is  pierced  in  the  middle  line  from  below 
with  a  straight  needle  on  a  fixed  handle.  A  straight  needle  passes  more 


AMPUTATION  OF  THE  CERVIX. 


283 


easily  through  the  dense  tissue  of  the  cervix  ;  if  the  cervix  does  not  pro- 
ject sufficiently  through  the  vulva  to  allow  of  the  straight  one  being 
used,  a  curved  one  is  required.  When  the  point  of  the  needle  projects 
as  far  as  the  eye,  this  is  threaded  with  a  long  wire  suture  and  then  drawn 
back  (fig.  169,  MN).  A  similar  thread  is  carried  through  on  either  side 
of  the  middle  line  so  that  the  cervical  canal  is  pierced  with  three  long 
sutures,  one  in  the  middle  of  it,  and  one  at  each  side  of  it.  The  cervix 
is  now  split  horizontally  with  the  knife  or  scissors  so  as  to  divide  it  into 
an  anterior  and  posterior  lip ;  this  horizontal  section  is  carried  as  far  as 
the  sutures,  so  that  they  are  exposed  at  the  bottom  of  the  incision.  We 
now  hook  them  up  in  turn  and  drag  the  loop  of  each  down  through  the 
wound  (fig.  169,  mn).  Each  loop  is  then  divided ;  the  three  sutures  are 
thus  converted  into  six — three  through  the  base  of  each  lip.  A  portion 


FIG.  168. 

MARCKWALD'S  METHOD  OF  SPLITTING  THE  CERVIX  into  an  anterior  and  a  posterior  lip  and  then 
uniting  cervical  to  vaginal  mucous  membrane  (Schroeder). 

of  the  anterior  lip  is  excised  along  the  line  1,  2,  3.  The  sutures  are 
now  vised  to  bring  together  the  margins  of  this  amputation.  The  pos- 
terior lip  is  next  treated  in  the  same  way.  Additional  sutures  are  put 
in  on  each  side  to  close  the  side  walls  of  the  cervix  (fig.  170,  *  and  y}. 
When  the  cervix  is  not  unusually  thick,  these  lateral  sutures  are  passed 
as  in  fig.  170;  but  when  the  cervical  walls  are  thick,  it  makes  a  neater 
stump  to  bring  these  sutures  also  out  through  the  cervical  canal  and 
unite  vaginal  to  cervical  mucous  membrane  all  round  (see  fig.  172). 

The  peculiarity  of  this  method  of  operating  is,  that  the  sutures  are 
introduced  before  the  knife  is  used.  The  advantages  of  this  are  the 
following  : — it  is  easier  to  pass  the  needle  through  the  dense  tissue  when 
the  cervix  is  fixed  with  the  volsella ;  the  sutures  serve  as  a  means  of 
traction  when  the  portion  grasped  by  the  volsella  has  been  cut  away ; 


284 


AFFECTIONS  OF  UTERUS. 


and  we  can  ligature  the  flaps  immediately  after  the  lip  has  been  ampu- 
tated and  thus  check  haemorrhage. 

M 


FIG.  169. 

DIAGRAM  OF  AMPUTATION  OF  CERVIX.  To  the  right  is  seen  the  cervix  with  the  ring  constricting  it, 
a  suture  MN  in  position,  the  cervix  split,  and  the  line  of  amputation  marked  1  to  6  ;  a,/, 
anterior  and  p.f.  posterior  fornix.  To  the  left  is  seen  the  cervix,  in  cross-section  ;  two  threads 
are  passed  and  the  needle  carried  through  but  not  yet  threaded  with  the  wire  jr. 

The  appearance  of  the  stump  after  the  sutures  have  been  twisted  is 
seen  at  fig.  171.     The  ends  are  left  long  enough  to  protrude  clear  of  the 


J 


n 


FIG.  170. 

THE  SUTURE  MN  has  been  divided  and  the 
halves  brought  down  the  canal  as  Mm, 
Nn  ;  the  lateral  ones  also,  x  x  and  y  y 
are  additional  side  Sutures. 


FIG.  171. 

APPEARANCE  OF  STUMP  of  fig.  170  when  Sutures  are 
twisted  up. 


vulva ;  the  free  ends  of  the  same  suture  are  twisted  together  to  keep 
them  separate  from  the  others  ;  finally,  all  the  ends  are  wrapped  in  a 


AMPUTATION  OF  THE  CERVIX.  285 

piece  of  lint  to  prevent  their  fretting  the  labia.  Catgut  is  being  used 
now  instead  of  wire  in  operations  on  the  cervix  to  obviate  the  necessity 
of  removal,  which  is  always  a  disagreeable  and  sometimes  a  painful  oper- 
ation ;  it  must  be  strong,  as  some  force  is  required  in  tying  it  tight  to 
secure  coaptation  of  surfaces. 

Removal  of  Silver-unre  Sutures  — The  sutures  are  removed  in  a  week's  Mode  of 

removing 
Sutures. 


FIG.  172. 
HEGAR'S  METHOD  OF  STITOHIXG  THE  CERVIX  after  the  circular  amputation  (Hegar  u.  Kaltenbach). 

time.  The  patient  is  put  in  the  Sims  position  and  the  Sims  speculum 
passed.  Slight  traction  is  made  on  a  suture,  and  if  the  twisted  knot  is 
visible,  we  clip  the  wire  with  the  wire  scissors.  Generally  we  find  the 
knot  is  embedded  in  tissue;  in  which  case  the  rake  (fig.  173)  is  used  to 
hook  up  the  loop.  In  snipping  the  loop  we  place  one  blade  of  the  scissors 
under  it,  and  then  press  the  tissue  back  from  the  wire  so  as  to  divide 
the  loop  as  far  away  from  the  knot  as  possible. 

Amputation  with  the  Ecraseur  or  with  the  Galvano-caustic  wire  is  not  Amputa- 
such  a  neat  method  of  operating  as  with  the  knife.     Further,  there  isj;craseur 

liability  to  closure  of  the  cervical  canal  through  cicatrisation;  this  mayorGalvan°- 

caustic 


I 


FIG.  173. 
POINT  OF  RAKE  ;  although  finely  made,  it  should  be  blunt.  (}). 

be  prevented  by  introducing  a  stem  pessary  after  amputation.  The 
galvano-caustic  wire  is  recommended  by  Barnes,  Thomas,  and  others ; 
its  use  has  been  followed  with  remarkably  good  results  in  the  hands  of 
Byrne  of  Brooklyn,  whose  valuable  paper  on  this  subject  should  be 
consulted. 

The  method  of  using  the  ecraseur  and  galvano-cautery  will  be 
described  under  amputation  of  the  cervix  for  carcinoma  (see  Chap. 
XLIL). 


286 


AFFECTIONS  OF  UTERUS. 


Diagnosis 
of  Hyper- 
trophy 
limited  to 
supra- 
vaginal 
portion  of 
Cervix. 


With  the  galvano-caustic  wire  we  must  see  that  the  wire  does  not  dip 
doumwards,  and  thus  "  scalp  "  instead  of  amputating  the  cervix.  The 
fact  that  the  galvano-cautery  diminishes  haemorrhage  is  of  no  advantage 
in  amputating  the  hypertrophied  cervix.  The  use  of  the  india-rubber 
ring  makes  this  a  bloodless  operation ;  and  the  introduction  of  the 
sutures  in  the  way  described  minimizes  the  danger  of  haemorrhage 
where  the  ring  is  not  employed. 

B.    HYPERTROPHY   OF   THE   SUPRA-VAGINAL   PORTION. 

The  existence  of  hypertrophy  limited  to  the  supra-vaginal  portion  of 


FIG.  174. 

HYPERTROPHY  OF  INTERMEDIATE  PORTION  OF  CERVIX.     The  anterior  fornix  is  obliterated  (Schroedcr). 

the  cervix  and  not  affecting  the  body  of  the  uterus  cannot  be  determined 
by  clinical  examination  alone.  The  obvious  reason  is  that  we  have  no 
means  of  ascertaining  in  a  case  of  hypertrophy  where  the  precise  upper 
limit  of  the  cervix  lies.  The  position  of  the  os  internum  cannot  be 
learned  from  the  sound,  and  the  distance  to  which  the  utero-vesical 
pouch  of  peritoneum  descends  can  only  be  ascertained  on  post-mortem 
examination.  We  cannot  affirm,  therefore,  that  the  hypertrophy  is 
limited  to  the  supra-vaginal  portion  of  the  cervix  and  that  it  does  not 
affect  the  body  of  the  uterus  as  well. 

In  the  present  state  of  our  knowledge  it  is  impossible  to  say  whether 
this  hypertrophy  is  primary  or  secondary.  We  believe  that  in  the  great 
proportion  of  cases  it  is  secondary  to  prolapsus  uteri.  It  has  also  been 
described  as  an  exceptional  occurrence  in  the  early  months  of 
pregnancy. 1 

By  French  and  by  many  German  gynecologists,  however,  hypertrophy 

1  By  Martin— Berliner  Gesellschaft  f.  Geb.  u.  Gyn.  1880. 


AMPUTATION  OF  THE   CERVIX.  287 

of  the  supra- vaginal  portion  of  the  cervix  is  considered  a  distinct  primary 
lesion.  Huguier  first  drew  attention  to  the  increase  in  the  length  of  the 
uterine  canal  in  cases  described  as  prolapsus  uteri ;  he  affirmed  that  the 
fundus  uteri  always  remained  in  its  normal  position,  and  that  the  os 
externum  came  to  lie  outside  the  vulva  because  the  cervix  had  increased 
in  length ;  this  hypertrophied  condition  of  the  cervix  was  occasioned  by 
a  prolapse  of  the  vaginal  walls  which  made  traction  on  the  cervix,  and 
thereby  stimulated  it  to  increased  growth. 

By  these  gynecologists,  three  forms  of  cervical  hypertrophy  are  de- Three 
scribed  according  to  the  portion  of  the  cervix  which  is  hypertrophied.  Cervical 

The  division  of  the  cervix  into  three  portions — a  vaginal,  an  intermediate,  Hyper- 
trophy. 


FIG.  175. 

HYPERTROPHY  OF  SUPRA-VAGINAL  PORTION  OF  CERVIX.     Both  fornices  are  obliterated  (Schroeder). 

and  a  supra-vaginal  portion — has  been  already  described  (see  page  16). 
The  vaginal  portion  is  limited  superiorly  by  the  insertion  of  the  anterior 
fornix ;  the  intermediate  by  that  of  the  posterior  fornix ;  the  supra- 
vaginal  by  the  os  internum.  Hypertrophy  of  the  vaginal  portion  is 
characterised  by  the  persistence  of  both  fornices  in  their  normal  position  ; 
it  has  been  already  described  (see  fig.  166).  In  hypertrophy  of  the  in- 
termediate portion  the  posterior  fornix  remains,  while  the  anterior  is 
obliterated  (see  fig.  174).  In  hypertrophy  of  the  supra- vaginal  portion 
both  anterior  and  posterior  fornices  are  obliterated  (see  fig.  175). 

In  the  accompanying  preparation  (fig.  176),  described  by  Barnes,  the 
elongation  affects  both  uterus  and  cervix — if  we  take  the  utero-vesical 
pouch  of  peritoneum  as  indicating  the  position  of  the  os  internum. 
Similar  specimens  are  figured  and  described  by  Winckel  (Die  Pathologic 
der  weiblichen  Sexual-Organe,  Tafel  XlXa),  and  by  Gallard  (Annales 
de  Gyn.  XXIV.,  p.  219). 


288 


AFFECTIONS  OF   UTERUS. 


Conoid 
Amputa- 
tion of 
Hyper- 
trophiecl 
Cervix. 


Treatment — While  hypertrophy  limited  to  the  vaginal  portion  of  the 
cervix  is  very  rare,  that  affecting  the  whole  cervix  and  usually 
associated  with  prolapsus  uteri  is  a  common  condition,  and  it  was  for 
it  that  the  various  modes  of  amputating  a  portion  of  the  cervix 
described  at  p.  281  were  introduced. 

Huguier,  who  first  exactly  described  supra-vaginal  hypertrophy, 
introduced  the  conoid  amputation.  One  incision  is  made  from  the 
posterior  foniix  obliquely  upwards  and  forwards  as  far  as  the  cervical 


FIG.  176. 

PROLAPSUS  UTERI  WITH  CERVICAL  ELONGATION  (Barnes)  ;  p,  p,  peritoneum. 

canal;  a  second  is  made  from  the  anterior  fornix  upwards  and  back- 
wards to  meet  the  latter ;  by  this  means  a  wedge-shaped  or  conical  piece 
of  the  supra-vaginal  portion  of  the  cervix  is  removed. 

Flap  The  flap  operation  already  described,  however,  gives  the  best  stump. 

Operation.  jn  amputating  for  supra-vaginal  hypertrophy,  the  relations  of  bladder 
and  peritoneum  of  the  pouch  of  Douglas  require  to  be  considered.  The 
bladder  invariably  descends  for  a  varying  distance  in  relation  to  the 


AMPUTATION  OF  THE   CERVIX. 


289 


front  of  the  hypertrophied  cervix.  The  peritoneum  of  the  pouch  of 
Douglas,  inasmuch  as  it  lines  the  upper  part  of  the  posterior  vaginal 
wall,  will,  when  that  wall  is  everted,  dip  down  alongside  of  the  hyper- 
trophied cervix.  If  the  posterior  fornix  is  not  obliterated,  the  peri- 
toneum will  not  descend  alongside  of  the  protruding  cervix. 

The  relations  of  the  bladder  and  peritoneum  are  represented  diagram- 
matically  in  fig.  177.  The  line  of  reflection  of  the  posterior  vaginal 
wall  on  to  the  cervix  indicates  how  much  is  vaginal  portion,  and  by 
passing  the  needle  below  that  line  we  keep  clear  of  the  pouch  of 


FIG.  177. 

AMPUTATION  OF  HYPERTROPHIED  CERVIX  IN  PROLAPSUS  UTERL  B  sound  in  bladder  ;  p  peritoneum 
of  pouch  of  Douglas.  The  sutures  are  passed  as  M  N,  and  the  cervix  split  laterally,  so  as  to 
form  an  anterior  lip,  which  is  amputated  along  lines  1,  2,  3,  and  a  posterior  lip  amputated  along 
4,  5,  6. 

peritoneum.  The  sound  passed  into  the  bladder  will  show  us  how  far 
down  that  organ  comes,  and  the  needle  is  brought  out  an  inch  below 
that  point. 

The  steps  of  the  operation  are  the  same  as  in  the  former  case. 

The  peritoneum  of  the  pouch  of  Douglas  has  been  frequently  cut  into 
without  bad  results  following,  so  that  many  operators  regard  this  as  an 
accident  of  little  importance. 


CHAPTER    XXIX. 

LACERATION  OF  THE  CERVIX  AND  ITS 
CONSEQUENCES. 

LITERA  TURE. 

Boer — Analysis  of  Twenty-seven  Operations  for  the  Restoration  of  the  Lacerated  Cervix 
Uteri,  with  special  reference  to  the  effect  on  sterility  and  labour :  Amer.  Jour. 
Obstet.,  1883,  pp.  295,  852.  Breisky— Wiener  med.  Wochenschrift,  1876,  Nos.  49-51. 
Also,  Prager  med.  Wochenschrift,  1876,  No.  18  and  1877,  No.  28.  Czempin— Risse 
des  Cervix  Uteri  ihre  folgen  und  operative  Behandlung  :  Zeit.  fiir  Geb.  undGyn.,  Bd. 
XII.,  S.  287.  Desvernine— These  de  Paris,  1879.  Dudley— New  York  Med.  Jour., 
Jan.  1878.  Emmet—  Surgery  of  the  Cervix:  Am.  Jour,  of  Obst.,  Feb.  1869;  ibid., 
Nov.  1874.  American  Practitioner :  Indianapolis,  Jan.  1877.  Principles  and  Practice 
of  Gynaecology,  p.  440  :  Philadelphia,  1884.  Eustache — La  Trachelorrhaphie  ou  opera- 
tion d 'Emmet :  Archiv.  de  Tocolog.,  1884,  p.  684.  Goodcll — Notes  of  one  hundred 
and  thirteen  cases  of  operation  for  laceration  of  the  cervix  :  Am.  Journ.  of  Obst., 
Jan.  1882.  Hegar — Operative  Gynakologie,  S.  538 :  Stuttgart,  1881.  Hewitt, 
Orally — Clinical  Lecture  on  Laceration  of  the  Os  and  Cervix  Uteri,  etc.  :  Brit.  Med. 
Journ.,  1886,  I.  p.  1.  Houzel — Note  sur  1'Operation  d'Emmet  ou  Trachelorraphie  : 
Annal.  de  Gyn.,  XXX.,  241  and  351.  Howitz — Gynakologiske  og.  Obstetriciske 
Meddelelser,  Bd.  I.,  Heft  3.  Johnson — Trachelorrhaphy  :  Amer.  Jour.  Obstet., 
1884,  p.  539.  Kaltenbach — Ueber  tiefe  Scheiden-u.  Cervicalrisse  bei  der  Geburt : 
Zeitschrift  f.  Geb.  u.  Gyn.,  Bd.  II.,  S.  274.  Klein— Prager  med.  Wochenschrift, 
1878,  No.  24.  Lee— The  Proper  Limitations  of  Emmet's  Operation :  New  York 
Med.  Jour.  Sept.  1881.  Macdonald,  Angus — The  Caiises,  Results,  and  Treatment 
of  Laceration  of  the  Cervix  :  Ed.  Med.  Jour.,  July  1882.  Munde — Am.  Jour, 
of  Obst.,  Jan.  1879;  Death  after  Trachelorraphy,  New  York  Med.  Jour.,  1883, 
p.  332.  Murphy — Observations  on  the  effects  of  Trachelorrhaphy  on  Fertility 
and  Parturition :  Amer.  Journ.  of  Obstet.,  Jan.  1883.  Nieberding — Ueber  Ectropium 
und  Risse :  Wiirzburg,  1879.  Noeyr/erath — Cervixrisse  und  Erkrankungen  der  Gebar- 
mutter :  Berl.  klin.  Wochenschr.,  1887,  No.  41 ;  and  (for  Discussion)  Archiv  f.  Gyn., 
Bd.  XXXI.,  S.  469.  Olshausen — Zur  Pathologic  der  Cervicalrisse :  Centralbl.  f. 
Gyn.,  1877.  Nr.  13.  Fallen— St.  Louis  Med.  and  Surg.  Jour.,  May  1868;  Richmond 
and  Louisville  Med.  Jour.,  1874  :  British  Med.  Jour.,  May  1881.  Park— Trachelorr- 
haphy :  Edin.  Med.  Jour.,  XXXIII.,  II.,  p.  1130.  Play  fair— Trachelo-raph6  :  Lond. 
Obstet.  Trans.,  1883,  and  Medical  Times  and  Gazette,  1885,  I.  340.  Roser— Das 
Ectropium  am  Muttermund  :  Arch.  f.  Heilk.  II.  Jalirg.,  2  H.,  1861.  Huge  u.  Veit— 
Zur  Pathologic  der  Vaginalportion ;  Stuttgart,  1878.  Sanger— Ueber  die  klinische 
Bedeutung  der  Cervixrisse  :  Centralb.  f.  Gyn.,  Bd.  XII.,  S.  441.  Simpson,  Sir  J.  Y. 
—Edin.  Jour,  of  Med.  Science,  1851,  p.  152.  Spiegelberg— Weber  Cervicalrisse,  ihre 
Folgen  u.  ihre  operative  Beseitigung:  Breslauer  artz  Zeitschrift,  1879,  No.  1. 
Van  de  Warker— Etiology  of  Lacerations  :  Am.  Journ.  of  Obst.,  Jan.  1882.  Thirty- 
one  operations  for  Repair  of  Laceration  of  the  Cervix  Uteri:  ibid.,  July  1883. 
Vuttiet— Douze  cas  d'operation  de  Trachelorrhaphie:  Archiv.  de  Tocolog.,  1884, 
p.  1000.  Wells,  B.  H.—  Possible  Dangers  of  Trachelorrhaphy  :  Amer.  Jour.  Obstet., 
1884,  p.  561.  Also,  The  Etiological  Relation  of  Cervical  Laceration  to  Uterine 
Disease :  Amer.  Jour.  Obs.,  1888,  p.  257.  Zinke— Emmet's  Operation :  Phil.  Med. 
Reporter,  Aug.  1885.  See  Index  of  Gynecological  Literature  in  the  Appendix  for 
recent  cases  of  the  Operation. 


LACERATION  OF  THE  CERVIX.  291 

THE  student  will  not  have  gone  far  in  the  clinical  study  of  Gynecology  Introduc- 
without  being  surprised  at  the  large  number  of  patients  who  refer  the  ory> 
commencement  of  their  illness  to  a  confinement  or  miscarriage.  They 
come  complaining  of  various  ailments — a  weak  back,  pain  in  the  side, 
white  discharge,  losing  too  much  at  the  monthly  time,  or  general 
unfitness  for  work.  On  physical  examination,  he  finds  a  variety  of 
conditions — a  fissured  and  thickened  velvety  cervix,  thickenings  in  the 
lateral  fornices  or  behind  the  uterus  often  displacing  it  by  traction,  and 
the  uterus  itself  enlarged.  We  do  not  mean  that  all  of  these  are  present 
in  one  case,  but  that  one  or  more  of  them  may  be  ;  nor  is  any  one 
symptom  invariably  connected  with  one  lesion.  He  asks  himself  why 
labour  is  so  often  the  starting-point  of  female  complaints ;  and  one 
important  reason,  though  by  no  means  the  only  one,  is  that  the  tear  of 
the  cervix  in  labour  literally  opens  the  door  to  a  variety  of  lesions. 
Cervical  catarrh  is  favoured,  if  not  started  (as  Emmet  says),  by  the  split 
condition  of  the  cervix  ;  the  raw  surface  has  admitted  septic  matter 
which  leads  to  chronic  inflammation  of  the  parametrium  with  all  the 
changes  in  the  train  of  parametritis;  and  sub-involution  is  kept  up  (if 
not  directly  by  the  tear,  as  Emmet  holds)  indirectly  by  the  consequent 
parametritis  which  Freund  has  shown  to  affect  the  venous  and  lymphatic 
circulation  in  the  uterus.  It  is  impossible  to  consider  laceration  of  the 
cervix  separate  from  the  results  which  in  the  great  majority  of  cases 
follow,  and  hence  this  chapter  deals  with  "  Laceration  of  the  Cervix 
and  its  Consequences."  Many  of  these  latter  being  distinct  lesions  in 
themselves,  will  be  treated  of  separately  in  the  following  chapters  and 
only  referred  to  here  in  their  relation  to  laceration  as  an  antecedent. 

For  the   recognition   of  laceration   of  the  cervix   as  a  distinct  and  Historical, 
important  lesion  we  are  indebted  to  the  genius  of  Emmet  of  New  York, 
who  was  the  first  to  insist  on  its  clinical  significance  and  elaborate  an 
operation  for  its  treatment. 

J.  H.  Bennet  of  London  had  previously  described  the  changes 
produced  in  the  cervix  by  its  laceration  in  labour,  unfortunately  attribut- 
ing them  to  a  process  of  ulceration.  Roser  of  Marburg  had  described 
the  pathology  of  the  condition;  but  its  importance  as  a  factor  in  uterine 
disease  was  brought  into  notice  by  Emmet's  first  paper  which  was 
published  in  1869,  seven  years  after  he  had  introduced  his  operation. 
Emmet's  views  as  to  the  importance  of  lacerations  of  the  cervix  have 
given  rise  to  a  great  deal  of  discussion ;  and  their  significance  is  a 
qucestio  vexata  in  Gynecology,  which  has  been  revived  in  the  last  two 
years  through  a  paper  by  Noeggerath  in  1887. 1  From  a  comparison  of 
fifty  gynecological  cases  in  which  laceration  was  present  with  another  fifty 
in  which  it  was  absent,  he  concludes  that  it  has  no  effect  on  fertility,  on 

1  Read  in  the  Gynecological  Section  of  the  Versammlung  deutscher  Xaturforscher  und  Aerzte  in 
Wiesbaden.  His  paper  and  the  others  referred  to  in  the  text  are  given  in  the  Literature. 


292 


AFFECTIONS  OF  UTERUS. 


the  length  or  position  of  the  uterus,  cervical  catarrh  or  ectropion,  or 
disease  of  the  uterus  generally.  His  paper  has  given  rise  to  considerable 
discussion  in  Germany,  America,  and  this  country ;  and  it  has  been 
shown  1  that  Noeggerath's  method  of  inquiry  is  in  several  respects 
fallacious,  and  that  the  clinical  evidence  proves  that  his  extreme 
position  is  indefensible. 

PATHOLOGY. 

Seat,  form,      The  commonest  seat  of  the  laceration  is  to  the  front  and  left  2  side  of 

of  lacera"*  the  cervix,  probably  because  the  long  diameter  of  the  child's  head  is  most 

tion-          commonly  in  the  right  oblique  diameter  of  the  pelvis,  and  the  thicker 

end  of  the  wedge  is  to  the  front.     The  next  in  frequency  is  a  double 

laceration — to  the  front  and  left,  and  to  the  back  and  right  sides.     Less 


FIG.  178. 

SINGLE  LACERATION.    The  flaps  are  held  apart  with  a  double  tenaculum  (Emmet). 

frequently  is  the  laceration  at  either  end  of  the  left  oblique  diameter. 
We  have  found  lacerations  to  the  front  and  right  side  in  cases  where 
the  head  presented  right  occipito-anterior.  The  form  of  the  laceration  is 
various — single  (see  fig.  178),  double  (see  Plate  XII.,  fig.  2),  or  multiple 
(see  fig.  179).  The  extent  of  the  laceration  varies,  from  a  mere  indenta- 
tion of  the  ring  of  the  os  externum  to  a  gaping  fissure  separating  the 
lips  of  the  cervix  up  to  the  vaginal  fornices.  Occasionally  it  extends 
into  the  roof  of  the  vagina, 3  and  is  marked  by  a  cicatricial  band  drawing 

1  See  the  papers  by  Siinger,  Park,  and  Wells  given  in  the  Literature. 

2  According  to  Emmet  and  Spiegelberg ;  Klein  and  Czempin  found  right-sided  laceration  more 
frequent. 

3  Czempin,  in  an  extremely  interesting  paper  on  cases  of  laceration  of  the  cervix  observed  in 
Martin's  Clinique  at  Berlin,  draws  especial  attention  to  these  tears  extending  into  the  fornix  which 
he  describes  as  "  Cervix-Laquearrisse."    They  are  not  infrequent  (having  been  present  in  sixty -eight 
out  of  his  two  hundred  and  eighty-seven  cases),  usually  unilateral,  and  more  frequent  with  single  than 
with  double  tears  of  the  cervix  itself.     Their  symptoms  are  more  marked,  due  to  the  changes  in  the 
parametrium. 


LACERATION  OF  THE  CERVIX. 


293 


the  cervix  to  one  side  ;  we  have  noticed  this  in  forceps  cases,  specially 
when  the  forceps  had  been  applied  before  the  os  was  dilated. 

Among  the  pathological  conditions  which  are  the  consequences  of  lacera-  Results. 
tion  are  the  following.  One  result  is  that  the  mucous  membrane  of  the 
cervical  canal  is  exposed,  and  the  occurrence  of  cervical  catarrh  favoured 
(v.  Cervical  Catarrh).  The  submucous  tissue  is  also  thickened  and  the 
whole  cervix  thus  hypertrophied. *  With  these  inflammatory  change^ 
there  is  eversion  of  the  lips  of  the  cervix,  although  this  is  sometimes 
counteracted  by  the  formation  of  cicatricial  tissue  in  the  cleft. 

Another  consequence  is  cellulitis  ;  frequently  we  find,  on  the  same  side 
as  the  laceration,  a  localised  cellulitis  in  the  shape  of  a  distinct  deposit, 
or  a  tense  condition  of  the  utero-sacral  or  broad  ligament,  accompanied 
with  tenderness  on  pressure  through  the  fornix.  This  tenderness,  as 


FIG.  179. 
MULTIPLE  OR  STELLATE  LACERATION  (Emmet). 

well  as  the  constant  pain  complained  of  in  the  side,  is  probably  due  to 
changes  in  the  sympathetic  plexus  in  the  connective  tissue  already  referred 
to  under  Parametritis.  Subinvolution  of  the  uterus  is  also  frequently 
present  ;  there  is  a  formation  of  cicatricial  tissue,  which  compresses  the 
veins  and  lymphatics  and  leads  to  passive  congestion  and  hypertrophy. 
The  compression  of  the  vessels  seems  sometimes  to  have  an  opposite 
result,  leading  to  atrophy  through  stoppage  of  nutrition. 

ETIOLOGY. 

A   laceration   of   the   cervix   will    be  found,    according   to  Emmet's  Frequency 
statistics,  in  32*8  per  cent,  of  parous  women  ;  according  to  Wells, 
takes  the  average  of  all  the  various  authorities,  in  32  per  cent.     Though 

1  Partial  hypertrophies  of  such  a  size  as  almost  to  form  a  tumour  sometimes,  but  very  rarely, 
occur.  Stratz  describes  three  cases,  in  one  of  which  the  tumour  weighed  2  Ibs.  (Zcitscli.  fur  Geb.  und 
Gyn.,  Bd.  xii.,  S.  229. 


* 


294  AFFECTIONS  OF  UTERUS. 

it  is  obvious  that  lacerations  may  be  produced  and  heal  again  so  that  all 
trace  of  them  escapes  notice,  we  cannot  affirm  that  the  cervix  is  lace- 
rated with  every  first  full-time  labour ;  but  when  present,  a  laceration 
of  the  cervix  (if  we  exclude  the  possibility  of  the  cervix  having  been 
divided  artificially)  is  the  most  reliable  diagnostic  of  a  former  parturition. 
It  must,  however,  be  remembered  that  a  divided  condition  of  the  cervix 
with  ectropium  of  the  cervical  mucous  membrane  has  been  described  as 
a  congenital  condition  by  Fischel  and  Kiistner ;  in  such  cases,  the 
everted  mucous  membrane  does  not  become  much  altered  and  retains 
the  arbor  vitae. 

We  should  have  expected  that  lacerations  would  be  more  readily 
produced  in  a  rapid  labour,  in  which  the  os  had  not  time  to  dilate ; 
Emmet  and  Fallen,  however,  have  found  that  they  are  more  commonly 
the  result  of  tedious  labours.  Spiegelberg  blames  early  rupture  of  the 
membranes  done  to  hasten  labour;  while  Klein  finds  them  most  frequent 
where  there  is  a  short  interval  between  rupture  of  the  membranes  and 
delivery  of  the  child,  as  also  where  the  child  is  heavy. 

Barker  and  Munde  both  draw  attention  to  the  fact  that  they  are  less 
common  among  the  wealthy  than  among  the  poor.  This  is  probably 
explained  by  the  better  care  and  longer  rest  in  the  puerperium  which 
the  former  enjoy. 

Produced  Even  during  pregnancy,  according  to  Nieberding,  fissuring  of  the 
pregnancy.  cervix  with  ectropium  is  produced.  He  examined  the  cases  admitted  to 
the  lying-in  hospital  at  Wurzburg  at  three  periods — during  pregnancy, 
as  shortly  as  possible  after  delivery,  and  on  dismissal.  Only  in  26  per 
cent  of  the  primiparse  examined  (thirty-eight  cases)  was  the  appearance 
of  the  cervix  normal  during  pregnancy ;  in  all  the  others  more  or  less 
ectropium  was  present.  In  50  per  cent,  there  were  in  addition  small 
fissures,  which  made  the  os  stellate  or  irregular  in  form. 

SYMPTOMS. 

Symptoms      It  is  very  important  to  know  what  symptoms  are  referable  to  a  lace- 
tion.          rated  cervix.     Those  who  revel  in  operative  treatment  ascribe  every 
pathological  condition  in  the  uterus  to  lacerations,  while  others  alto- 
gether deny  that  they  have  any  pathological  significance. 

We  advance  the  following  considerations  in  regard  to  the  symptoms. 

1.  Lacerations   of  the   cervix    in    themselves  produce    no    symptoms. 
Haemorrhage  may  arise  at  the  time  of  production,  but  is  not  a  symptom 
of  the  persistence  of  the  laceration. 

2.  Other  pathological  conditions  arise  secondarily  as   the  result  of 
the  laceration,  of  which  the  most  important  are  cervical  catarrh  and 
cellulitis  ;    cicatricial    tissue    in    the    cleft    produces    reflex    nervous 
symptoms. 

We    sometimes   find    a   well-marked    laceration    by   chance,    as    it 


LACERATION   OF  THE  CERVIX.  295 

were,  the  patient  having  had  no  symptoms  referable  to  a  pelvic 
cause. 

Frequently  she  complains  of  leucorrhcea  and  symptoms  common  to 
pelvic  or  uterine  inflammation.  Menstruation  is  often  irregular,  in- 
creased in  50  per  cent,  according  to  Emmet's  statistics ;  this  is  in  many 
cases  due  to  subinvolution.  Sterility,  when  present,  is  probably  due  to 
the  accompanying  catarrh  ;  and  the  tendency  to  abortion^  to  the  secondary 
changes  in  the  uterus  or  parametrium.  Neuralgia  is  sometimes  present, 
which  may  show  itself  locally  in  excessive  tenderness  to  touch  at  the 
seat  of  laceration  and  has  been  compared  to  the  sensitiveness  present  in 
toothache.  In  other  cases  it  has  taken  the  form  of  neuralgic  pain  in  the 
pelvis  generally,  often  in  the  groin  and  extending  down  the  leg,  or 
sympathetic  neuralgia  elsewhere.  Emmet  and  others  record  cases  in 
which  persistent  neuralgia  disappeared  on  excision  of  the  cicatricial  plug 
in  a  lacerated  cervix.  Other  reflex  disturbances  (such  as  cataleptic  con- 
vulsions, persistent  salivation,  profuse  sweating,  hysterical  anuria)  have 
disappeared  after  Emmet's  operation.  General  weakness  and  inability 
to  work  are  present  here  as  in  other  chronic  conditions. 

The  relation  of  laceration  to  malignant  disease,  of  which  it  seems 
sometimes  to  be  the  starting-point,  will  be  considered  under  Cancer  of 
the  Uterus. 

DIAGNOSIS. 

This  presents,  in  many  cases,  no  difficulty. 

The  finger  feels  the  indentation  or  fissuring  of  the  vaginal  portion.  Occasional 
Sometimes  the  cervical  canal  is  patulous,  and  admits  the  distal  phalanx  iu  recogni- 
of  the  finger  easily.     Difficulty  in  diagnosis  arises  when  there  is  muchtlon- 
eversion  of  the  mucous  membrane  of  the  cervical  canal  with  thickening 
of  the  cervical  tissue  ;  the  fissure  is  thus  obliterated,  because  the  circle 
of  the  os  is  not  formed  of  the  os  externum  but  of  a  higher  unfissured 
portion  of  the  canal.     This  thickening  and  the  velvety  feeling  of  the 
everted  mucous  membrane  lead  us  to  suspect  the  condition. 

The  speculum  shows  the  cleft  in  the  cervix  with,  in  the  great  majority 
of  cases,  round  it  appearances  which  will  be  more  fully  described  under 
Cervical  Catarrh.  We  see  a  bright  red  irregular  patch  on  one  side  of 
or  surrounding  the  os ;  from  its  granular  appearance,  its  vascularity, 
and  the  fact  that  it  bleeds  easily,  it  resembles  an  ulcerated  surface. 
For  this  reason  it  is  often  described  as  "  ulceration  "  of  the  cervix,  but  it 
is  no  more  an  ulceration  than  is  the  inflamed  mucous  membrane  of  the 
conjunctiva.  By  ulceration  we  understand  a  destruction  and  loss  of 
tissue.  The  epithelium  and  subepithelial  tissue  may  be  destroyed  as 
an  immediate  result  of  injury  during  labour;  but  the  raw-looking  sur- 
face, appearing  secondary  to  and  also  independent  of  lacerations  (see 

1  To  the  importance  of  which  Graily  Hewitt  has  called  attention  in  a  recent  paper  (toe.  cit.). 


296  AFFECTIONS  OF  UTERUS. 

Catarrh  in  Nulliparae),  is  not  an  ulcerated  surface  and  should  therefore 
not  be  treated  as  such. 

As  already  mentioned  (p.  114),  Sims'  speculum  must  be  used;  the 
other  forms  only  mask  the  laceration. 

For  the  appearance  presented  by  the  various  forms  of  laceration  when 
seen  in  the  speculum,  the  student  should  compare  fig.  178  and  fig.  179. 
The  difference  between  the  colour  of  the  everted  cervical  mucous  mem- 
brane and  that  of  the  vagina  is  represented  in  Plate  XII.,  figs.  1  and  2. 
A  beautiful  series  of  chromo-lithographs  is  appended  to  Munde's  article 
(Am.  Jour,  of  Obstet.,  Jan.  1879),  which  illustrates  the  various  degrees 
of  laceration.  The  most  complete  series  is  in  Nieberding's  pamphlet 
which  gives  representations  of  the  cervix  uteri  before  and  after  parturi- 
tion, both  in  primiparse  and  multiparse ;  the  colouring,  however,  is 
unnatural. 

The  microscopic  changes  which  produce  the  appearance  simulating 
ulceration  will  be  described  under  Cervical  Catarrh. 

The  tenacula  are  a  valuable  adjunct  in  examination  with  the  specu- 
lum. If  we  place  one  in  the  anterior  and  one  in  the  posterior  lip,  and 
roll  these  in  on  one  another,  the  raw-looking  surface  will  in  many  cases 
disappear.  This  easily  demonstrated  fact  had  not  been  recognised  till 
Emmet  drew  attention  to  it,  and  based  on  it  the  operation  which  will 
be  always  associated  with  his  name.  By  thus  rolling  the  lips  inwards, 
we  restore  the  laceration  and  see  the  extent  of  it  so  as  to  judge  of  the 
possibility  of  approximating  the  lips  with  sutures. 

TREATMENT. 

From  what  has  been  said  in  the  introductory  paragraph,  and  also 
under  "  Pathology,"  it  is  evident  that  the  treatment  of  laceration  of  the 
cervix  means  much  more  "than  the  closure  of  the  split.  Emmet  in 
his  operative  procedure  not  only  closes  the  laceration  but  excises  the 
cicatricial  tissue ;  he  also  makes  his  patients  undergo  a  long  preparatory 
treatment  directed  to  the  cervical  catarrh.  The  cases  calling  for  his 
operation  are  much  fewer  than  might  at  first  sight  be  supposed, *  because 
no  laceration  however  well  marked  calls  for  treatment  unless  it  is  pro- 
ducing* symptoms  ;  and  there  are  other  operations  (Schroeder's  and 
Martin's)  for  removing  the  consequences  of  laceration  which  are  as 
efficient  as  Emmet's. 

operation  ^he  stitching  up  of  a  laceration  immediately  after  parturition  was 
for  lacera- 
tion. *  Principles  and  Practice  of  Gynaecology  :  1884,  p.  483.  The  conservation  as  to  this  operation 
which  exists  in  this  country  is  almost  justified  by  what  Emmet  says  in  his  letter  given  in  the 
interesting  tabulated  record  of  opinions  of  the  leading  operators  which  Zinke  has  collected  as  to 
when  and  when  not  the  operation  is  to  be  performed;  the  italics  are  ours.  "The  Operation  has 
long  since  passed  out  of  my  hands,  and  so  fully  endorsed  that  I  have  no  fear  for  its  future.  The 
great  point  is  to  check  the  abuse,  which  is  fearful.  Every  one  feels  competent  to  perform  it ;  it  is 
done  without  the  proper  preparatory  treatment,  and  with  no  special  purpose.  I  believe  in  nine 
ca*e»  out  often,  where  it  is  done,  or  attempted,  the  execution  of  the  operation  is  defective  and  with- 
out any  benefit  to  the  patient." 


LACERATION  OF  THE  CERVIX.  297 

first  performed  by  Fallen  of  New  York.  Having  failed  to  check  by  the 
tampon  post  partum  haemorrhage  from  a  lacerated  cervix,  he  passed 
Sims'  speculum  and  sewed  up  the  laceration  with  silver-wire  sutures  ; 
this  checked  the  haemorrhage.  We  have  never  had  occasion  to  perform 
the  "  immediate  "  operation  ;  injections  of  very  hot  water  have  always 
sufficed  to  check  haemorrhage.  Considering  the  liability  to  septic 
inflammation  in  the  puerperal  condition,  we  would  be  very  chary  about 
operating  unless  the  haemorrhage  were  considerable  and  not  diminished 
by  hot  injections. 

The  paring  of  the  edges  of  an  old  laceration  and  uniting  of  them  Emmet's 
with  sutures  is  known  as  "Emmet's  operation,"  which  is  a  simpler  and  Operation' 
more  suggestive  name  than  "Trachelorrhaphy." 

Preliminaries  to  Emmet's  Operation.  —  The  patient  should  use  hot-  water  Prelimi- 
injections  for  some  weeks  previous  to  the  operation,  and  apply  a  blister  nanes- 
if  there  be  any  indication  of  cellulitis.     Emmet  lays  great  stress  on  this 
preparatory  treatment,  and  says  that  we  should  not  operate  so  long  as 
there  is  any  tenderness  on  pressure  in  the  fornices.     He  further  recom- 
mends, in  cases  where  the  cervix  is  thickened  and  the  mucous  follicles 
enlarged,  scarification  of  the  cervix  and  painting  with  iodine  or  tannin 
and  glycerine. 

The  Operation.     The  following  instruments1  are  required  :  —  Emmet's 

Vaginal  douche,  Dissecting  forceps, 


Sims'  speculum,  Short   needles  (fig.    105)   straight  ated 

Volsellae,  and  curved, 

Tenacula,  Needle  holder, 

Rubber  ring,  Medium  silver  wire,  or  catgut. 

Bistoury  and  scissors, 

The  patient  is  placed  under  chloroform  in  the  lithotomy  posture  (in 
the  semiprone  posture  by  Emmet,  but  this  does  not  give  the  operator  so 
much  room)  ;  the  sacral  segment  is  drawn  back  with  the  speculum  by  an 
assistant,  and  the  cervix  is  laid  hold  of  with  the  volsella  and  drawn 
down.  The  uterus  may  be  curetted  at  this  stage.  Draw  the  edges  of 
the  laceration  together  with  the  tenacula  to  see  how  much  tissue  must 
be  pared  from  the  edges  of  the  cleft  to  allow  it  to  be  sewed  iip,  and  then 
proceed  to  operate.  Slip  the  rubber  ring  over  the  volsella  on  to  the 
cervix  and  place  it  so  as  to  constrict  the  base  ;  this  prevents  bleeding 
and  thus  allows  the  operator  to  see  that  the  edges  are  completely  pared, 
which  is  essential  to  union  of  the  raw  surfaces.  Wash  out  the  vagina 
with  carbolised  water.  When  possible,  continual  irrigation  is  kept  up 
during  the  operation  ;  with  this,  the  india-rubber  ring  is  not  required 
as  the  stream  of  water  keeps  the  denuded  surface  always  clean.  Now 

1  It  is  of  great  advantage,  as  Martin  has  pointed  out,  to  curette  the  uterus  before  operating  on  the 
cervix  ;  this  can  be  done  at  the  one  operation,  in  which  case  we  need  the  curette  and  sounds  dressed 
with  cotton-wool  dipped  in  iodine  or  carbolic  acid  in  addition  to  the  instruments  mentioned. 


298 


AFFECTIONS   OF  UTERUS. 


pare  the  edges  of  the  laceration  with  the  scissors  or  knife  (fig.  1 80) ; 

J! 


FIG.  180. 
OPERATION  FOB  LACERATED  CERVIX  ;  a  6  extent  of  denuded  surface. 

scissors  are  preferable,  because  they  cut  with  greater  ease  and  rapidity. 


FIG.  181. 

EXTENT  OF  DENUDED  SURFACE  AND  COURSE  OF  SUTURES  ACCORDING  TO  EMMET  (Emmet). 
The  sutun-s  are  passed  in  order  1234;  the  course  of  suture  4  alone  is  indicated  by  letters  abed. 

With  long-bladed  scissors  we  can  remove  the  tissue  from  one  edge  of  the 


LACERATION  OF  THE  CERVIX. 


299 


laceration  with  a  steady  clean  cut  right  into  the  angle ;  Emmet  lays 
great  stress  on  the  removal  of  the  cicatricial  tissue  in  the  angle  but 
uses  the  bistoury  to  do  this.  When  the  laceration  is  bilateral  this 
must  be  done  on  both  sides.  Fig.  181  shows  the  extent  of  surface 
denuded  by  Emmet  in  a  case  of  bilateral  laceration.  Great  care  must 
be  taken  to  leave  a  broad  strip  (broader  than  represented  in  fig.  181) 
undenuded  in  the  middle  line  to  form  the  walls  of  the  cervical  canal. 
Now  introduce  the  sutures ;  these  if  of  wire  are  about  eight  inches  long 
so  that  both  ends  protrude  from  the  vagina,  and  are  well  adapted  to  the 
eye  of  the  needle  so  as  not  to  obstruct  its  passage.  Emmet  recommends 
the  round  needle  as  it  makes  a  smaller  hole  and  is  therefore  followed  by 
less  haemorrhage ;  when  the  tissues  are  dense,  the  lance-shaped  point 
perforates  more  easily.  Catgut x  has  the  great  advantage  over  silver 
wire,  that  the  stitches  do  not  require  to  be  removed  afterwards; 


FIG.  182. 

MODE  OF  PASSING  SUTURES  ;  a  6  denuded  surface  as  in  fig.  181.    The  sutures  are  passed  in  order 

as  numbered. 

strong  sutures  are  necessary,  as  some  force  is  needed  to  tie  them  tight. 
Pass  the  sutures  as  in  fig.  182,  beginning  at  the  upper  part  of  the 
wound  :  each  is  drawn  half  through  but  is  not  twisted  up  till  its  fellows 
are  in  position,  as  it  is  sometimes  necessary  (when  the  tissues  are  thick) 
to  pass  the  needle  first  through  one  lip  and  then  through  the  other ; 
they  are  then  twisted  up ;  the  ends  are  brought  out  at  the  vaginal 
orifice,  tied  together,  and  wrapped  round  with  a  piece  of  wadding 
(fig.  183). 

Emmet  cuts  the  sutures  short,  but  the  long  ends   facilitate  their 
removal.     No  special  regimen  is  required  afterwards,  the  diet  need  not 

1  Meinert  recommends  passing  the  catgut  right  through  the  cervix  and  fixing  the  ends  with  shot 
on  plates  :  Eine  sichere  Catgutnahtfur  die  Emmet'sche  Operation  :  Archiv  f.  Gyn.  XXXIII.,  S.  310. 


300 


AFFECTIONS  OF  UTERUS. 


be  restricted.  Secondary  haemorrhage  has  sometimes  followed  the 
operation :  it  is  best  checked  by  passing  a  suture  through  the  cervix 
higher  up  and  tying  it  tightly  on  the  side  from  which  the  haemorrhage 
comes  so  as  to  constrict  the  vessels  in  the  cervix. 

Removal  of  wire  sutures. — The  stitches  are  removed  on  the  seventh  or 
eighth  day.  To  do  this  we  require  speculum,  wire-scissors,  rake,  and 
forceps.  The  rake  is"  almost  indispensable  in  removing  sutures  from  the 
cervix  or  vagina;  it  is  represented  and  described  at  fig.  173.  The 
sutures  are  removed  from  above  downwards  ;  if  we  reverse  the  order,  we 
may  tear  the  lower  portion  apart  in  removing  the  upper  sutures  ;  if  the 
surfaces  have  not  entirely  united,  the  lower  sutures  should  be  left  in 
for  a  few  days  longer. 

The  effect  of  the  operation  on  sterility  has  given  rise  to  a  great  deal 


FIG.  183. 

APPEARANCE  OF  CERVIX  WITH  SUTURES  TWISTED  UP.    They  are  left  long  so  as  to  extend  to  vaginal 
orifice  and  are  removed  in  order  as  numbered. 

of  discussion.  Wells  gives  in  his  paper  an  interesting  table  of  statistics 
as  to  subsequent  conceptions,  and  affirms  that  the  operation  increases 
fertility;  the  proportion  (one-fourth)  of  cases  fertile  after  Emmet's 
operation  is,  however,  the  same  as  Emmet  gives  for  cases  of  laceration 
generally,  i.e.  whether  operated  on  or  not. 

The  cicatrix  does  not  cause  difficulty  in  subsequent  parturition.  The 
cervical  catarrh  may  persist  after  the  operation.  Sometimes  metritis, 
cellulitis,  or  peritonitis  has  unfortunately  followed  it.  Six  fatal  cases 
have  been  collected  by  Wells. 


LACERATION  OF  THE  CERVIX.  301 

Other  operations  to  meet  the  consequences  of  laceration. — Emmet's  opera- 
tion is  directed  not  only  against  the  split  but  also  its  conse- 
quences, the  cicatrisation  and  the  cervical  catarrh.  Simply  to  close 
an  old  split  would  be  as  meaningless  as  shutting  the  stable  door 
in  the  proverb.  For  the  treatment  of  the  catarrh,  we  have  also 
Schroeder's  excision  of  the  mucous  membrane  of  the  cervix  and  Martin's 
amputation  and  excision,  both  of  which  will  be  described  in  the  next 
chapter. 

For  extensive  tear  into  the  fornix1  which  has  resulted  in  cicatri- 
sation in  the  parametrium  with  lateral  displacement  of  the  uterus, 
Martin  has  introduced  as  a  special  operation2  the  separation  of  this 
cicatricial  tissue  from  the  cervix.  Under  chloroform,  in  the  lithotomy 
posture,  the  cervix  is  drawn  over  with  forceps  from  the  affected  side 
and  a  semilunar  incision  made  in  the  cicatrix  in  the  fornix,  following 
the  contour  of  the  cervix.  This  may  be  sufficient;  or  it  may  be 
necessary  in  addition  to  cut  out  a  portion  of  the  cicatrised  tissue.  The 
antero-posterior  incision  is  then  stitched  so  as  to  bring  front  and  back 
together  and  thus  make  the  line  of  junction  transverse. 

1  See  footnote  3,  p.  292. 

2  Czempin  (loc.  cit.)  gives  three  cases  in  which  marked  symptoms  disappeared  after  this  operation, 
and  also  a  tabular  report  of  nine  more  recent  cases  in  Martin's  clinique  with  similar  good  results. 


CHAPTER  XXX. 

CHRONIC  CERVICAL  CATARRH. 

LITERA  TDRE. 

Barnes — Diseases  of  "Women :  London,  1878,  p.  530.  Bennett,  G.  H. — Practical  Treatise 
on  Inflammation,  Ulceration,  and  Induration  of  the  Neck  of  the  Uterus  :  London, 
1845.  Candia — L'amputazione  della  porzione  dell'  utero  come  cura  radicale  delle 
erosioni  e  della  metrite  parenchimale  cronica :  Annali  di  Ostet.,  1888,  463. 
Duncan,  Matthews — Diseases  of  Women  :  Lond.,  1886.  Fischel — Bin  Beitrag  zur 
Histologie  der  Erosionen  der  Portio  vaginalis  uteri:  Archiv  f.  Gyn.,  Bd.  XV., 
S.  76.  Fritsch — Erosionen,  Ectropium  und  Cervicalcatarrh  :  Billroth  u.  Luecke's 
Handbuch  der  Frauenkrankheiten,  Stuttgart,  1885.  Hennig — Der  Katarrh  der 
inneren  weiblichen  Geschlechtstheile :  Leipzig,  1862.  Hildebrandt — Ueber  den 
Katarrh  der  weiblichen  Geschlechtsorgane  :  Volkmann's  Sammlung  klin.  Vortrage, 
Leipzig,  1872,  No.  32.  Hofmeier — Folgezustande  des  chronischen  Cervixkatarrhs 
und  ihre  Behandlung :  Zeitsch.  f.  Geb.  u.  Gyn.,  Bd.  IV.,  S.  331.  Klotz— Gynako- 
logische  Studien  iiber  die  pathologischen  Veranderungen  der  Portio  vaginalis  Uteri : 
Wien,  1879.  Kustnet — Beitrage  zur  Lehre  von  der  Endometritis,  Erosion  und 
Ectropium:  Jena,  1883.  Mundi — The  treatment  and  curability  of  chronic  uterine 
catarrh  :  Amer.  Journ.  of  Obstet.,  1883,  p.  857.  Buge  and  Veit — Zur  Pathologic 
der  Vaginalportion  :  Zeitschrift  f.  Geb.  u.  Gyn.,  Bd.  II.,  S.  415.  Schroedei — 
Krankheiten  der  weiblichen  Geschlechtsorgane :  Leipzig,  1879,  S.  122.  Smith, 
Heywood — So-called  Ulceration  of  the  Womb  :  Obst.  Journ.  of  Great  Britain,  1876, 
p.  604.  Steavenson — Note  on  the  use  of  Electrolysis  in  Gynecological  Practice,  and 
Discussion :  Trans.  Lond.  Obs.  Soc.,  June  and  July  1888.  Thomas — Diseases  of 
Women  :  London,  1880,  pp.  275  and  336.  Vulliet — De  la  dilatation  permanente  de 
1'ut^rus  :  Arch,  de  Toe.,  1886,  p.  933. 

ACUTE  catarrh  of  the  cervix  is  known  to  us  only  as  part  of  a  general 
catarrh  affecting  both  body  and  cervix,  and  will  be  described  under 
Acute  Endometritis.  Chronic  catarrh  occurs  localised  in  the  cervical 
mucous  membrane ;  it  is  a  very  common  condition  and  one  of  the  most 
troublesome  which  the  practitioner  has  to  treat. 

DEFINITION. — A  chronic  inflammatory  process  affecting  the  mucous, 
membrane  lining  the  cervical  canal. 

SYNONYMS. — Cervical  endometritis,  Endo-cervicitis. 

PATHOLOGY. 

The  mucous  membrane  of  the  cervical  canal  is  inflamed.  When  the 
os  externum  has  been  lacerated,  the  lips  gape  and  the  mucous  membrane 
is  thus  everted  ;  on  bringing  the  margins  of  the  laceration  together,  this 
eversion  will  disappear.  Further,  there  are  granular  patches  with 
irregular  outline  which  extend  beyond  the  limits  of  the  os  externum ; 


PLATE   m. 


EROSION  AND  LACERATION  OF  CERVIX  (RuoE  AKD  VEIT). 


CHRONIC   CERVICAL   CATARRH. 


303 


these  have  a  red  appearance  resembling  the  cervical  mucous  membrane, 
and  are  therefore  sharply  denned  from  the  paler  mucous  membrane 
which  covers  the  vaginal  portion  of  the  cervix. 

This  last  condition  was  till  late  years  generally  held  to  be  an  "ulcera-  Pathology 
tion"  and  is  still  described,  even  in  recent  English  works,  under 
name.  The  term  should,  however,  be  discarded  as  based  on  an  erroneous 
pathology  and  suggesting  most  pernicious  treatment.  The  cause  of  the 
error  is  easily  explained  :  a  raw-looking  granular  surface  was  seen  with 
the  speculum;  the  raw  appearance  was  ascribed  to  the  loss  of  the 
epithelium,  and  this  supposition  was  supported  by  the  microscopic 
examination  of  specimens  taken  from  the  dead  body,  in  which  the 
epithelium  had  been  macerated  and  removed  ;  the  granular  points  were 
supposed  to  be  the  subjacent  papillae  which  had  become  hypertrophied. 

Both  of  these  suppositions  have  been  shown  to  be  erroneous  by  the  Ruge  and 
careful  investigations  of  Huge  and  Veit,  who  examined  specimens  of  the  inv'estiga- 

tions. 


FIG.  184. 
PAPILLARY  FORM  OF  EEOSION  (Schroeder). 

so-called  ulcerations  cut  fresh  from  the  living  subject ;  they  demonstrated 
(1)  that  the  apparently  raw  surface  is  covered  with  epithelium,  (2)  that 
the  granular  points  are  new  formations  and  have  no  connection  with  the 
papillae  of  the  mucous  membrane. 

The  microscopic  appearance  of  the  mucous  membrane  described  by 
them  is  as  follows.  The  surface  is  covered  with  a  single  layer  of  epi- 
thelium ;  the  cells  are  smaller  than  those  which  line  the  normal  cervical 
canal,  and  being  narrow  and  long  have  a  palisade-like  arrangement ;  the 
thin  layer  of  cells  allows  the  subjacent  vascular  tissue  to  shine  through, 
hence  the  redness  of  colour.  The  surface  is  further  thrown  into  numerous 
folds  producing  glandular  recesses  and  processes  ;  these  processes  cause 
the  granular  appearance  of  the  surface.  The  condition  is  well  seen  in 
Plate  XII.,  and  constitutes  the  simple  erosion :  fig.  1  shows  such  an 
erosion  as  seen  in  the  speculum  :  fig.  3  shows  a  microscopic  section  of  the 


304 


AFFECTIONS  OF   UTERUS. 


same,  stained  with  carmine  ;  the  left  half  of  the  section  corresponds  to 
the  deep  red  portion  of  fig.  1,  the  right  half  to  the  paler  portion  outside 
of  this.  If  the  recesses  be  long  and  narrow,  the  surface  is  split  up  into 
distinct  papillae  ;  this  constitutes  the  papillary  erosion  (see  fig.  184). 
If  the  ducts  of  the  glandular  recesses  become  obliterated,  the  section  will 
distend  the  gland  below  and  produce  retention-cysts  ;  these  will  increase 
in  size,  and  may  come  to  the  surface  and  burst.  Thus  there  is  formed 
the  follicular  erosion  (see  fig.  185). 

The  raw-looking  surface  is  therefore  a  newly-formed  glandular  secreting 
surface,  resembling  in  structure  the  cervical  mucous  membrane.  This 
addition  to  the  extent  of  secreting  surface  increases  the  leucorrhceal 
discharge  which  is  the  leading  symptom. 

These  observations  of  Huge  and  Veit  have  been  confirmed  in  their 
essential  points  by  Fischel  and  other  observers  ;  Fischel  considers  the 
secreting  processes,  while  being  new  formations,  to  have  the  structure 
of  papillae  and  not  to  be  mere  foldings  of  the  mucous  membrane. 

While  there  is,  therefore,  no  disagreement  as  to  the  microscopical 
so-called  "ulcerations,"  the  origin  of  this  new  epithelial 


Origin 

E  *th  1'  1  aPPearance 

new  forma- 

tion. 


FIG.  185. 
FOLLICULAR  FORM  OF  EROSION  (Schroeder). 

structure  is  disputed.  Ruge  and  Veit  hold  that  this  single  layer  of  small 
cylindrical  cells  is  produced  by  proliferation  of  the  cells  of  the  deepest 
layer  of  the  rete  Malpighi,  while  those  of  the  superficial  layer  are  shelled 
off;  the  appearance  seen  in  fig.  185  favours  this  view.  It  will  be 
observed  also  that  they  regard  the  simple  follicular  and  papillary  "ulcera- 
tions" as  the  results  of  one  and  the  same  process,  viz.,  proliferation  of 
epithelial  cells.  On  the  other  hand,  those  red  patches  are  generally  con- 
tinuous with  the  mucous  membrane  of  the  cervical  canal  and  resemble  it 
in  their  microscopic  structure  ;  it  is  therefore  much  more  probable  that 
they  are  occasioned  by  proliferation  of  the  epithelium  which  lines  the 
cervical  glands,  leading  to  an  extension  of  the  glandular  surface  beyond 
the  os  externum.  Fischel  holds  that  there  is  not  only  the  proliferation 


CHRONIC   CERVICAL   CATARRH.  305 

of  epithelial  cells,  but  of  connective  tissue  ;  and  that  according  to  the 
preponderance  of  the  one  over  the  other,  the  follicular  or  papillary  forms 
are  produced.  He  also  thinks  erosions  are  due  to  the  persistence  of  the 
cylindrical  epithelium  (found  outside  the  os  externum  in  the  foetus)  into 
adult  life,  and  the  desquamation  of  the  squamous  epithelium  which  had 
come  to  cover  it. 

The  question  as  to  the  origin  of  the  cylindrical  epithelium  found  in 
erosions  is  rendered  more  difficult  by  the  fact  that  the  boundary-line 
between  the  squamous  epithelium  outside  of  and  the  cylindrical  within  the 
cervical  canal  varies  at  different  periods  of  development  and  in  different 
individuals.  In  the  foetus,  according  to  Ruge's  investigations,  the  cylin- 
drical epithelium  extends  down  the  vagina  also ;  and  we  have  a  hint 
of  the  persistence  of  this  foetal  condition  in  the  congenital  ectropium 
described  by  Fischel.  Klotz  describes  two  types  of  cervix  characterised 
by  the  distribution  of  the  squamous  epithelium  :  one,  cavernous  in 
texture,  and  having  the  squamous  epithelium  extending  some  distance 


FIG.  186. 

TRUE  ULCERATION  OF  THE  CERVIX.  At  the  sides  of  diagram  is  seen  the  normal  epithelium,  which 
is  prolonged  in  processes,  e.  p.  between  the  connective  tissue  papillae  ;  e  is  superficial  layer  of 
squamous  epithelium  reduced  to  a  thin  layer  at  e'  ;  c  t,  tissue  of  mucosa  infiltrated  with  small 
cells  ;  b  v,  blood-vessels  surrounded  by  small-celled  infiltration  (Fischel). 

into  the  cervix  ;  the  other,  glandular  in  its  substance,  and  having  the 
squamous  epithelium  stopping  at  the  usual  seat  of  the  os  externum. 

The  foregoing  description  of  the  microscopic  changes  makes  it  evident  Nomen- 
that  the  process  is  not  one  of  "  ulceration  ;  "  and  this  term  should,  there- 


fore,  be  abandoned.     The  German  term  Erosion  is  open  to  a  similar  changes  in 
criticism.     "Ectropium"  or  "Eversion  of  the  mucous  membrane"  de-  Catarrh. 
scribes  the  condition  in  its  relation  to  laceration,  but  does  not  describe 
the  extension  of  the  secreting  surface  beyond  the  os  externum  ;  the  term 
is  preferable  to  "  ulceration,"  as  it  is  at  least  not  misleading.     Thomas 
describes  these  conditions  under  the  name  of  "Granular  and  Cystic 
Degeneration  of  the  Cervix  Uteri."     This  term  is  based  on  the  naked  eye 
appearance  of  the  cervix,  and  conveys  no  idea  as  to  the  pathological  change 
which  takes  place.     Under  granular  degeneration,  he  describes  the  pap- 


306 


AFFECTIONS  OF   UTERUS. 


Catarrhal 
Patches. 


True 

Ulcera- 

tions. 


Ovula 

Nabothii. 


Cysts  in 
the  Cervix. 


Normal 
and  Patho 
logical 
conditions 
of  Cervix 
contrasted. 


illary  form ;  under  cystic  degeneration,  the  follicular.  As  we  are  not  in 
a  position  to  introduce  a  term  based  on  pathology,  it  is  preferable  to 
designate  it  according  to  its  symptom  as  Cervical  Catarrh.  The  red 
patches  which  lie  outside  the  os  externum,  we  shall  speak  of  as  "  catarrhal 
patches" 

Sometimes  a  true  ulcerated  process — destruction  of  epithelium  with 
inflammation  of  connective  tissue — does  occur ;  such  a  condition  is 
represented  in  fig.  186. 

Along  with  those  changes  in  the  mucous  membrane,  chronic  inflam- 
matory changes  occur  in  the  other  tissues  of  the  cervix.  There  is 
increased  formation  of  connective  tissue,  which  produces  antero-posterior 
thickening  and  sometimes  elongation.  The  secretion  in  the  obstructed 
glands  becomes  inspissated,  and  hence  the  retention  cysts  are  felt  as 
firm  pea-like  bodies — ovula  Nabothii — in  the  substance  of  the  cervix 
or  projecting  from  it ;  or  their  contents  may  suppurate  and  form  small 
abscesses.  As  there  are  no  racemose  glands  on  the  vaginal  portion 
beyond  the  limits  of  the  os  externum  (see  Histology  of  Normal  Cervix, 
p.  21),  these  ovula  Nabothii  must  be  produced  from  the  glands  of  the 
mucous  membrane  of  the  cervical  canal  or  from  the  newly-formed 
glandular  tissue.  Fritsch  draws  attention  to  the  fact  that  the  glands  of 
the  cervix  are  enormously  hypertrophied  during  pregnancy,  so  that  the 
cervix  becomes  almost  a  glandular  organ ;  the  persistence  of  this  con- 
dition after  the  puerperium,  may  explain  the  increased  glandular 
formation  which  is  described  above  as  the  chief  pathological  element 
in  cervical  catarrh. 

Sometimes  we  find  a  single  large  cyst  in  the  cervix,  due  to  obstruction 
of  the  mucous  glands.  When  it  is  in  the  substance  of  the  wall,  the  soft 
bulging  into  the  cervical  canal  and  the  accompanying  menorrhagia  may 
lead  one  to  suspect  commencing  sarcomatous  infiltration.  Puncturing 
with  a  trocar  removes  a  clear  or  straw-coloured  fluid,  rich  in  mucous 
corpuscles. 

The  microscopic  pathology  of  the  cervix  has  only  of  recent  years  been 
carefully  investigated,  and  there  are  many  points  on  which  definite 
information  has  not  as  yet  been  obtained.  The  following  is  a  brief 
summary  of  the  pathological  changes  described,  which  are  best  under- 
stood by  comparison  with  the  microscopic  structure  of  the  normal 
vaginal  portion. 

NORMAL  CONDITION.  The  vaginal  portion  is  covered  on  its  vaginal 
surface  with  many  layers  of  squamous  epithelium,  resting  on  papillae  of 
connective  tissue ;  there  are  no  mucous  follicles.  The  cervical  canal  is 
lined  with  a  single  layer  of  cubical  epithelium  (ciliated  only  on  the 
ridges),  folded  so  as  to  form  shallow  recesses  which  do  not  branch  ; 
there  are  racemose  mucous  glands,  which  have  branching  ducts.  The 
substance  of  the  cervix  is  made  up  of  connective  tissue. 


CHRONIC   CERVICAL   CATARRH.  307 

PATHOLOGICAL  CHANGES.  These,  according  to  the  extent  and  dura- 
tion of  the  process,  affect  the  three  elements — epithelium,  glands, 
connective  tissue. 

The  epithelium  of  the  cervical  canal  may  be  simply  exposed 
(ectropium  after  laceration),  or  it  may  be  inflamed.  When  inflamed,  the 
folding  of  the  mucous  membrane  is  greatly  increased  so  that  the  surface 
has  a  papillary  or  granular  appearance.  Further,  this  inflamed  mucous 
surface  may  be  found  extending  beyond  its  normal  limit  (the  os 
externum)  in  the  form  of  red  patches  (catarrhal  patches)  which  are 
smooth  or  granular. 

The  glands  hypertrophy  and  new  glands  form  as  the  result  of  the 
proliferation  of  epithelium  described  above.  The  openings  of  the  glands 
are  at  first  restricted  to  the  area  covered,  with  a  single  layer  of  cubical 
epithelium,  but  their  branching  ends  extend  below  the  limiting  surface 
of  stratified  squamous  epithelium.  Their  ducts  become  obstructed,  and 
retention  cysts  form  not  only  on  the  red  patches  but  also  underneath  the 
adjacent  apparently  normal  vaginal  mucous  membrane.  They  may 
remain  as  little  nodules  in  the  mucous  membrane,  or  may  come  to  the 
surface  and  burst ;  in  the  latter  case,  the  cubical  epithelium  and  papillae 
on  the  inner  wall  of  the  cystic  gland  are  exposed  and,  being  now  on 
a  free  surface,  proliferate.  When  the  glands  are  the  special  seat  of  the 
pathological  changes,  the  whole  substance  of  the  cervix  is  converted  into 
a  cystic  mass. 

The  connective  tissue  always  increases  in  amount,  specially  when  the 
process  is  chronic.  This  increase  constitutes  the  "areolar  hyperplasia" 
of  Thomas. 

ETIOLOGY. 

The  most  important  cause  is,  undoubtedly,  the  injury  of  the  cervix  Frequenc 
produced  in  parturition ;  hence  cervical  catarrh  is  common  in  parous  ?*  j?/1*,^ 
women.       How  this  injury  produces  the  inflammatory  condition  is  a  parse, 
disputed  point.     Emmet  refers  it  to  the  persistence  of  the  split  in  the 
cervix,  and  holds  that  the  exposure  of  the  mucous  membrane  to  friction 
against  the   vaginal  walls   leads  to  irritation   and   inflammation ;  but 
we  frequently  see  cases  of  well-marked  lacerations  without  consequent 
cervical  catarrh.     It  is  admitted  by  all  that  the  existence  of  lacerations 
greatly  favours  the  development  of  catarrh. 

Other  less  important  causes  are  the  spread  of  inflammation  from  the 
vagina  upwards  (vaginitis,  which  may  be  simple  or  gonorrhoeal),  and 
from  the  endometrium  downwards.  The  latter  is  favoured  by  the  fact 
that  the  discharges  from  the  endometrium  necessarily  flow  over  the 
cervix  and  irritate  it. 

Cervical  catarrh  is  the  most  frequent  complication  of  retroflexion  of 
the  uterus.  The  flexion  favours  gaping  of  the  lacerated  cervix  and 
produces  passive  congestion  of  the  cervical  tissues. 


308  AFFECTIONS  OF  UTERUS. 

SYMPTOMS. 

These  are — Leucorrhcea ; 

Pain  in  back  and  loins,  increased  on  exercise  ; 
Irregular  menstruation ; 
Sterility. 

Leucorrhcea  is  the  prominent  symptom.  Under  normal  conditions  the 
secretion  from  the  mucous  membrane  of  the  uterus  and  cervix  is  not 
sufficient  to  attract  attention;  when  it  is  excessive,  it  is  termed 
leucorrhoea  (\ewc6s  white,  p<?w  to  flow)  or  in  popular  language  "  whites." 
A  transparent  leucorrhoea  from  the  cervix  and  uterus  occurs  before  and 
after  the  menstrual  flow  ;  this  is  a  hyper-secretion  dxie  to  temporary 
congestion. 

Characters      The  secretion  from  the  glands  of  the  cervical  canal  is  clear  and  viscid, 

Leucor^ICa  resembling  unboiled  white  of  egg.     It  becomes  of  an  opaque  white  when 

rhcea.         mucous   corpuscles  are   abundant,  yellowish   when  pus  corpuscles  are 

present.     Frequently,  it  is  tinged  with  blood  from  the  blood-vessels  of 

the  newly-formed  vascular  tissue. 

Pain  in  the  back  and  loins  is  present,  as  in  all  uterine  disease.  It  is 
aggravated  on  active  exercise,  such  as  walking  and  riding,  or  whatever 
causes  friction  of  the  cervix  against  the  vaginal  walls. 

Menstruation  is  irregular,  and  often  increased  in  quantity ;  this  is 
probably  due  to  extension  of  inflammation  upwards  to  the  endometrium. 
We  must  take  care  not  to  mistake  leucorrhcea  tinged  with  blood  for  the 
regular  menstrual  flow. 

Sterility  is  often  present.  In  nulliparse  with  a  small  os  externum,  the 
plug  of  mucus  in  the  cervical  canal  is  alleged  to  be  a  bar  to  conception. 
In  multipart,  we  have  seen  conception  take  place  even  though  there  was 
a  deep  laceration  and  well-marked  catarrh ;  the  presence  of  catarrh, 
however,  though  not  an  obstacle  to  conception,  greatly  diminishes  its 
probability. 

PHYSICAL   SIGNS. 

Condition  On  vaginal  examination,  the  condition  of  the  cervix  is  found  to  vary 
in  Chronic  according  as  the  patient  is  nulliparous  or  multiparous  and  the  disease  of 
Catarrh.  iong  or  short  duration.  In  a  nullipara,  the  cervix  feels  puffy  and  large, 
the  margins  of  the  os  soft  and  velvety  (when  there  is  eversion  with 
extension  of  catarrhal  area  beyond  the  os  externum) ;  or  the  os  and 
cervix  are  apparently  normal  but  movement  causes  pain  (when  the 
catarrhal  area  does  not  extend  beyond  the  os  externum).  In  a  multipara, 
the  existence  of  a  laceration  must  first  be  determined  and  the  extent  of 
it  noted  ;  the  margins  of  the  os  are  soft  and  velvety,  and  pea-like  nodules 
(Nabothian  follicles)  are  felt  on  and  sometimes  round  them ;  polypoidal 
projections  may  be  present  and,  more  rarely,  the  cervix  is  converted 
into  a  mass  of  cysts ;  the  os  is  usually  gaping  so  that  the  finger  can  be 


CHRONIC  CERVICAL   CATARRH.  309 

passed  into  the  cervical  canal,  where  the  mucous  membrane  has  an 
irregular  surface  and  is  often  thrown  into  longitudinal  ridges. 

The  speculum  is  now  employed;  its  use  must  always  be  preceded 
a  careful  examination  with  the  finger  to  ascertain,  when  laceration  isspecuium 

present,  the  undisturbed  relations  of  the  lips  of  the  cervix.     Neither  ?f  ^eifvix, 

in  Catarrh. 

finger  nor  speculum  alone  is  sufficient,  we  must  employ  both,  and  learn 
to  associate  what  is  felt  by  the  finger  (e.g.,  lacerations,  velvety  mucous 
membrane,  pea-like  follicles)  with  what  is  seen  with  the  speculum.  The 
superiority  of  the  Sims  speculum  for  examination  is  very  marked,  as  it 
exposes  the  lips  of  the  cervix  without  disturbing  the  relations. 

In  a  nullipara,  we  see  the  os  apparently  normal  but  with  a  tenacious 
plug  of  mucus  projecting  through  it  ;  or  there  may  be  red  catarrhal 
patches  such  as  are  represented  in  Plate  XII.  ,  fig.  1,  which  shows  very 
well  the  contrast  between  the  appearance  of  these  patches  and  the 
surrounding  mucous  membrane  ;  no  chromo-lithograph,  however,  per- 
fectly displays  the  natural  colours. 

In  a  multipara,  a  laceration  is  sometimes  evident.  Oftener  it  escapes 
recognition  ;  the  os  appears  to  be  wide  and  unfissured,  while  on  both 
lips  there  is  a  red  velvety  surface  (Plate  XIL,  fig.  2)  ;  if,  now,  tenacula 
be  fixed  in  the  gaping  lips  and  those  rolled  in  on  one  another,  the  red 
surfaces  will  disappear  and  a  bilateral  laceration  become  evident.  Some- 
times, white  cicatricial  tissue  indicates  the  situation  of  the  laceration. 
Though  the  lips  are  thus  approximated,  a  red  surface  is  often  visible 
because  the  catarrhal  area  has  spread  beyond  the  os  externum.  The 
obstructed  Nabothian  follicles  appear  as  bluish-red  projections  from  the 
mucous  membrane  ;  occasionally,  they  form  small  polypi. 

DIAGNOSIS    AND    DIFFERENTIAL    DIAGNOSIS. 

The  diagnosis  between  cervical  and  vaginal  catarrh  is  made  clear  by  Diagnosis 
using  the  speculum,  for  we  see  in  the  former  case  the  leucorrhoea  coming  fromen 


from  the  cervix  and  having  the  characters  above  described.  Should 
discharge  not  be  profuse  enough  to  be  seen  with  the  speculum,  we  mayrho3a, 
employ  the  method  recommended  by  Schultze  for  diagnosing  between 
uterine  and  vaginal  catarrh.  The  vagina  is  douched  out  in  the  evening, 
and  a  tampon  soaked  in  a  solution  of  tannin  is  placed  against  the  os 
externum  ;  in  the  morning  the  tampon  is  removed  through  the  speculum, 
and  we  note  the  quantity  and  character  of  the  discharge  which  has 
accumulated  upon  it. 

The  diagnosis  between  cervical  catarrh  and  endometritis  is  difficult,  from 
and  in  many  cases  cannot  be  made  ;  when  cervical  catarrh  is  present,  we  metritis. 
cannot  be  positive  that  there  is  not  some  endometritis  as  well.     Increase 
in   the   length  of  the   uterine   cavity   (especially  with   tenderness  or 
irregularities   of  the   mucous   membrane)   ascertained   by  the   sound, 
indicates  endometritis.     When  the  cervix  is  much  thickened  and  indu- 


310 


AFFECTIONS  OF  UTERUS. 


rated,  we  may  suspect  the  commencement  of  malignant  disease  ;  this 
will  be  considered  under  Carcinoma  of  the  Cervix. 

PROGNOSIS. 

In  this  we  must  consider  the  constitutional  health  of  the  patient,  the 
duration  of  the  symptoms,  and  the  extent  to  which  the  tissues  are 
affected.  According  to  Thomas,  the  prognosis  is  less  favourable  when 
there  is  considerable  secretion  of  mucus  with  little  apparent  "  granular 
degeneration."  The  practitioner  will  often  find  that  cases  of  cervical 
catarrh  have  already  passed  through  several  hands,  and  he  should  there- 
fore be  on  his  guard  in  offering  hopes  of  speedy  cure. 

TREATMENT. 

Constitu-        In  the  first  place,  special  attention  must  be  given  to  the  patient's 
^ori^1     *  aeneral  health  :  if  we  trust  to  local  treatment  alone,  we  shall  often  be 

treatment   y 

d 


important. 


FIG.  187. 

HEALING  OF  A  CATARRHAL  PATCH  TREATED  BY  ASTRINGENT  OR  ANTISEPTIC  INJECTIONS  (Hofmeier). 
a  to  6,  newly-formed  squamous  epithelium  ;  from  c  to  cf,  is  seen  alteration  of  the  epithelium  at 
the  mouths  of  the  glands ;  d,  d,  glands  with  ducts  obliterated  ;  e,  gland-duct  which  has  persisted. 

disappointed.  We  should  recommend  change  of  air  and  light  nourishing 
food.  A  certain  amount  of  exercise  is  valuable ;  but  too  much  of  it, 
specially  of  riding,  is  injurious.  Tonics  (such  as  arsenic,  quinine,  and 
iron)  are  useful.  Disturbances  of  the  digestive  system,  which  are 
frequent  in  chronic  cases,  must  be  treated  as  each  case  indicates. 
Complete  rest  from  sexual  activity  is  advisable ;  this  can  often  be  secured 
by  recommending  that  the  patient  go  away  from  home  for  a  time. 

Cervical  catarrh  is  in  some  cases  only  a  local  manifestation  of  a  con- 
stitutional state  such  as  tuberculosis  or  anaemia. 

The  local  treatment  varies  according  as  the  patient  is  nulliparous  or 
multiparous.  In  both  cases  we  must  be  prepared  to  carry  out  a  system 
of  treatment  which  lasts  for  weeks. 


CHRONIC   CERVICAL   CATARRH. 


311 


1.  In  nulliparce  we  begin  with  a  course  of  vaginal  injections  of  hot  Local 
water.     These  are  used  freely,  from  ten  minutes  to  a  quarter  of  an  hour,  j£ x 
every  night.     To  the  simple  water,  astringents  or  antiseptics  are  added  :  parse, 
sulphate  of  zinc  (3j  to  the  pint) ;  sulphate  of  alumina  or  sulphate  of 
copper  (5ij  to  the  pint),  or  corrosive  sublimate  (1  to  4000). 

The  action  of  these  on  the  catarrhal  patches  has  been  specially 
investigated  by  Hofmeier  and  by  Kiistner.  The  former  found  that 
such  a  patch,  treated  by  daily  vaginal  injections  of  pyroligneous  acid, 
became  gradually  encroached  on  by  the  surrounding  squamous  epithe- 
lium's creeping  in  tongue-like  processes  over  the  cylindrical  epithelium. 


FIG.  188. 

FORCEPS  DBE3SED  WITH  COTTON  WADDING. 

The  more  superficial  glands  become  filled  up  with  the  squamous 
epithelial  cells:  the  deeper  ones  had  their  ducts  narrowed  or  even 
plugged,  while  the  gland-cavity  persisted  below  (fig.  187).  Kiistner 
found  that  similar  changes  could  be  produced  by  antiseptic  douches. 

If  the  os  be  narrow,  it  is  good  to  notch  it  bilaterally  with  the  scissors. 
This  acts  beneficially  by  allowing  the  mucus  to  escape  freely.  Munde 
recommends  the  trimming  of  the  lips  of  the  cervix  so  as  to  produce  a 
funnel-shaped  os. 

When  we  find  that  the  secretion  continues  copious  in  spite  of  the 
frequent  injections,  we  must  make  a  local  application  to  the  mucous 


FIG.  189. 

BARNES'  SPECULUM  for  introduction  of  medicated  cotton  wool  into  the  vagina  (Barnes). 

membrane.  Of  applications  the  best  are  iodine  (the  tincture  or  the 
strong  liniment)  and  carbolic  acid,  the  former  in  milder  and  the  latter 
in  more  severe  cases.  The  liquor  hydrargyri  pernitratis  is  recommended 
by  Heywood  Smith,  and  chromic  acid  is  much  praised  by  De  Sinety. 
In  making  these  applications  we  proceed  as  follows.  The  mucus,  which 
would  prevent  the  action  of  the  medicament  on  the  mucous  membrane, 
is  first  thoroughly  removed  by  the  forceps  dressed  with  cotton  wool  as 
represented  at  fig.  188.  A  second  pair  of  forceps,  covered  merely  with 
a  film  of  cotton  wadding,  is  now  dipped  in  the  medicament  and  applied 


312  AFFECTIONS  OF  UTERUS. 

to  the  surface.  Should  the  canal  be  narrow,  a  sound  dressed  as  for 
endometric  applications  (see  fig.  196)  is  preferable.  Care  is  taken  that 
there  be  no  free  drop  of  the  solution  on  the  cotton  wool,  which  might 
fall  on  the  vaginal  mucous  membrane  ;  after  the  application  is  made,  a 
pledget  of  cotton  wadding  with  glycerine  is  placed  below  the  cervix. 

Rarely  in  nulliparse  is  the  pathological  process  so  extensive  as  to 
require  operative  means  for  removing  cervical  tissue. 

2.  In  multipart.  Here  the  cervical  catarrh  is  usually  associated  with 
other  conditions — retroflexion,  subinvolution,  and,  especially,  marked 
laceration  of  the  cervix.  The  first  treatment  indicated  is  to  diminish 
the  passive  congestion  of  the  cervix  by  hot-water  injections  with 
astringents  or  antiseptics,  and  the  use  of  the  glycerine  plug.  The 
latter  is  prepared  as  already  described  (p.  204),  and  should  be  renewed 
daily.  The  patient  can  introduce  it  herself  with  Barnes'  speculum 
(fig.  189).  A  simpler  means  is  to  draw  the  string  through  a  piece  of 
glass  tubing,  and  to  keep  it  taut  with  the  finger  on  the  end  of  the  tube 
till  the  plug  is  carried  into  the  roof  of  the  vagina ;  then  the  finger  is 
removed  and  the  tube  slipped  out  over  the  string.  If  the  uterus  be 
retroflexed,  it  should  be  replaced  and  kept  in  position  by  a  pessary. 
Even  where  it  is  not  retro  verted,  a  pessary  is  often  useful  in  lifting  the 
uterus  upwards  in  the  pelvis  and  diminishing  passive  congestion.  In 
cases  where  there  is  a  distinct  laceration  of  the  cervix,  and  specially 
where  the  catarrhal  patches  can  be  made  to  disappear  by  rolling  the 
lips  inwards  on  each  other,  Emmet's  operation  is  indicated. 

Depletion  Local  depletion  by  scarification  or  leeches  was  formerly  much  employed, 
cation  or  but  is  not  used  now ;  its  effects  are  only  transitory.  Scarification  is 
Leeches.  <jone  best  through  the  Fergusson  speculum,  and  with  a  lancet-shaped 
bistoury;  a  number  of  small  punctures  are  made,  from  a  quarter  to 
half-an-inch  in  depth.  Leeches  are  applied  as  follows : — Fergusson's 
speculum  is  passed ;  a  pledget  of  lint,  with  string  attached,  is  placed 
in  the  cervical  canal  to  prevent  their  crawling  upwards  into  the  uterine 
cavity ;  a  little  blood  is  drawn  by  superficial  scratches  and  three  or 
four  leeches  thrown  into  the  speculum,  and  pushed  up  towards  the 
cervix  with  a  pledget  of  cotton  wadding.  We  must  watch  the  speculum 
lest  the  leeches  slip  out ;  after  the  speculum  and  leeches  are  removed, 
the  vagina  is  douched  with  a  tepid  injection  of  carbolised  water. 

Scarification  is,  however,  useful  for  another  object.  When  there  are 
hard  knobby  retention  cysts  producing  irritation  by  the  pressure  of  their 
contents,  the  puncturing  of  these  diminishes  the  chronic  inflammation. 
Paquelin's  cautery  is  also  used  to  puncture  the  cervix ;  but  this  use  of 
it  belongs  rather  to  the  treatment  of  the  hypertrophy  of  the  cervix  in 
Chronic  Metritis. 

In  very  chronic  cases,  the  only  remedy  is  the  destruction  of  the 
diseased  glandular  tissue — just  as  in  tonsilitis  we  partially  excise  the 


CHRONIC   CERVICAL   CATARRH. 


313 


tonsils.  This  has  been  done  by  the  application  of  strong  caustics  or  the 
cautery.  The  zinc-alum  sticks  introduced  by  Skuldberg  of  Stockholm 
are  recommended  highly  by  Matthews  Duncan.  They  are  made  by 
fusing  together  equal  parts  of  sulphate  of  zinc  and  sulphate  of  alumina, 
and  running  into  moulds.  The  stick  is  pushed  into  the  cervix,  and  a 
plug  of  wadding  laid  in  the  vagina  to  keep  it  in  place  and  receive  the 
discharge.  The  student  must  discriminate  this  use  of  a  powerful  caustic 
once  for  all  from  the  repeated  touching  of  the  surface  with  a  milder 
caustic  just  as  one  would  touch  a  slow  ulcer — a  treatment  which  cannot 
be  too  strongly  condemned. 

Electricity  has  been  used  both  in  France  and  this  country  with  the 
same  object,  viz.,  the  cauterisation  of  the  cervical  glands.  An  electrode 
with  a  rounded  end  (or  a  uterine-sound  one  if  it  has  to  be  passed  up 
the  canal)  is  connected  with  the  negative  pole  of  the  battery,  while  the 
positive  pole  is  placed  on  the  surface  of  the  skin.  Several  cases1  have 


FIG.  190. 


FIG.  191. 


SCHROEDER'S  EXCISION  of  the  CERVICAL  Mucous  MEMBRANE  in  cervical  catarrh.  Fig.  190  LINE  of 
INCISION  in  Mucous  MEMBRANE.  Fig.  191  Mucous  MEMBRANE  EXCISED  and  flap  be  turned  in 
on  ab  (Schroeder). 

been  treated  successfully  by  this  method,  but  it  remains  to  be  seen 
whether  it  possesses  advantages  over  other  forms  of  cauterisation  to 
compensate  for  the  difficulties  in  its  use. 

Thomas  recommends  the  steel  curette  for  the  removal  of  the  diseased 
glands ;  it  is  applied  "  so  forcibly  as  to  remove  the  arbor  vitse  and 
mucous  glands  from  the  os  internum  to  the  os  externum.  Sometimes 
a  second  operation  in  two  or  three  weeks  after  the  first  has  been 
necessary,  and  sometimes  even  a  third." 

Schroeder  used  the  knife,  and  operated  as  follows.     The  cervix  is  laid  Schroeder's 
hold  of  with  two  volsellse,  one  on  each  lip,  and  drawn  downwards.     It  is  f0r  Cervical 
divided  laterally  as  far  as  the  fornix  with  the  scissors,  so  as  to  form  an  Catarrh, 
interior  and  a  posterior  lip  which  are  separate  as  far  as  the  vaginal  roof 

1  Lovell  Drririf  and  Gibbons— ~Brit.  Med.  Journ.,  1888,  I.,  p.  1274.     Touret— Nouv.  Arch.  d'Obstet. 
et  de  Gyn.,  April,  1887. 


314 


AFFECTIONS  OF  UTERUS. 


(fig.  190).  A  transverse  incision  (seen  in  section,  at  a,  in  fig.  191)  is 
made  across  the  base  of  the  anterior  lip,  dividing  the  whole  thickness 
of  the  cervical  mucous  membrane.  He  next  pierces  the  point  of  the  lip 
at  c,  pushing  the  knife  in  the  direction  bb  till  it  reaches  the  cross 
incision  a  ;  he  carries  the  blade  outwards  first  to  one  side  and  then  to 
the  other,  so  that  all  outside  of  the  line  a  b  c  is  cut  away.  The  flap 
of  cervix  is  now  turned  in,  and  stitched  as  in  fig.  191.  The  advantage 
claimed  for  this  method  of  operating  is  that  the  degenerated  cervical 
mucous  membrane  is  replaced  by  vaginal  mucous  membrane  which 
shows  no  tendency  to  degenerate.  Schroeder  operated  thus  more 
than  three  hundred  and  fifty  times  (two  deaths),  and  with  very  good 
results  as  to  the  cure  of  the  catarrh. 


FIG.  191A. 

MARTIN'S  METHOD  OF  EXCISING  THE  Mucous  MEMBRANE  OF  THE  CERVIX  (Martin). 

The  continuous  black  line  shows  line  of  excision,  which  is  higher  up  in  the  fornix  than  in  Sg.  190 ; 

the  dotted  line  is  the  course  of  the  suture  introduced  after  the  piece  of  the  lip  is  excised. 

Martin  of  Berlin  in  excising  the  diseased  mucous  membrane  sometimes 
removes  more  of  the  substance  of  the  cervix,  as  fig.  19lA  shows,  thus 
combining  amputation  with  excision.  He  splits  the  cervix  into  two 
lips,  cuts  through  the  cervical  mucous  membrane  in  the  posterior  lip 
above  the  diseased  portion,  then  removes  as  much  of  the  lip  as  is 
necessary,  and  stitches  it.  The  anterior  is  treated  in  the  same  way ; 
and  then  the  sides  are  sutured — the  sutures  often  requiring  to  be 
passed  deeply  to  control  bleeding.  In  introducing  these  last  the 
volsella  can  be  taken  out  and  the  cervix  held  down  by  the  sutures  in 
the  two  lips. 


CHAPTER  XXXI. 

ENDOMETRITIS. 

LITERATURE. 

Atthill — On  Endometritis :  Dublin  Jour,  of  Med.  Sc.,  Jan.  1873.  Barnes— Diseases  of 
"Women  :  London,  1878,  p.  530.  Braun,  Carl — Therapie  der  Metritis  und  Endometri- 
tis, etc.  :  Wiener  med.  Wochenschrift,  1873,  Nos.  39-43.  De  Sinety — Gynecologic, 
p.  327 :  Paris,  1879.  DoUris — De  1'Endometrite  et  de  son  Traitement  (with 
Discussion) :  Archiv.  de  Toe.,  1887,  pp.  97,  145,  193,  314,  460.  Fritsch— Dilatation 
of  the  Uterus  and  In tra-uterine  Therapeutics  :  Amer.  Journ.  of  Obstet.,  1883,  p.  113. 
Guirin — De  la  Metrite  aigue  :  Annales  de  Gyne'colog.,  Juillet,  1874 ;  and  Arch,  de 
Tocologie,  Juillet,  1877.  Heinricius — Ueber  die  chronische  hyperplasirende  Endo- 
metritis :  Arch.  f.  Gyn.  Ed.  XXVIII.,  S.  163.  Heitzmann— Pathologic  und 
Therapie  der  nicht  puerperalen  Endometriden  :  Centralb.  f .  die  gesammte  Therapie, 
1886,  Nos.  1-5.  Hennig — Der  Katarrh  der  inneren  weiblichen  Geschlechtstheile  : 
Leipzig,  1862.  Klob — Pathologische  Anatomie  der  weiblichen  Sexualorgane  :  Wien, 
1864,  S.  211.  Kiistner — Beitrage  zur  Lehre  von  der  Endometritis :  Jena,  1883. 
Olshauscn — Ueber  chronische  hyperplasirende  Endometritis  des  Corpus  Uteri : 
Archiv  f.  Gynakologie,  Band.  VIII.,  Heft  1.  Play  fait — Intra-uterine  Medication  : 
Brit.  Med.  Jour. ,  December  1869 ;  Ibid. ,  March  1880 ;  Lancet.  January  and  February, 
1873.  R6camicr — Des  graniilations  dans  la  cavite  de  1 'uterus :  Annal.  de  Therap., 
Nov.  1846.  See  also  Union  Med.  de  Paris,  Juin  1850.  Routh— On  "Fundal 
Endometritis:"  Lond.  Obst.  Trans.,  Vol.  XII.  Cases  of  Menorrhagia  treated  by 
injections,  etc.  :  Lond.  Obst.  Trans.,  Vol.  II.  Schroeder— Krankheiten  der  weib- 
lichen Geschlechtsorgane  :  Leipzig,  1886,  S.  108.  Simpson,  Sir  J.  Y. — Diseases  of 
Women  :  Edinburgh,  1873,  p.  736.  Smith,  Tyler— Pathology  and  Treatment  of 
Leucorrhcea  :  London,  1855.  Thomas — Diseases  of  Women :  London,  1880,  p.  268. 
See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

INFLAMMATORY  action  may  affect  the  peritoneal  covering,  the  muscular 
substance,  or  the  mucous  membrane  of  the  uterus,  producing perimetritis, 
metritis,  or  endometritis.  Usually  we  find  more  than  one  of  these  con- 
ditions present  at  once,  as  the  inflammatory  action  is  rarely  limited  to 
one  of  these  coats.  Perimetritis  is  only  a  part  of  pelvic  peritonitis, 
under  which  head  it  has  already  been  considered. 

We  now  consider  inflammation  limited  to  the  mucous  membrane  of 
the  uterus — endometritis,  which  may  be  acute  or  chronic. 

DEFINITION. — Inflammation  of  the  mucous  membrane  of  the  uterus. 

SYNONYMS. — Uterine  catarrh,  internal  metritis. 

PATHOLOGY. 

Ill  acute  endometritis  both  body  and  cervix  are  involved,  and  usually 
the  underlying  muscular  coat  also.  The  mucous  membrane  is  swollen 


316 


AFFECTIONS  OF  UTERUS. 


Micro- 
scopic 
changes  in 
Chronic 
Endo- 
metritis. 


and  soft,  and  covered  with  red-stained  mucus  or  creamy  pus.  Extra- 
vasations of  blood  are  present  as  red  streak  or  patches.  These  changes 
are  not  so  marked  in  the  cervical  mucous  membrane  as  in  that  of  the 
body ;  the  vaginal  portion  has  the  same  appearance  as  during  pregnancy, 
being  soft  and  swollen  and  showing  red  catarrhal  patches  round  the  os. 

The  ciliated  epithelium  is  destroyed,  and  sometimes  casts  of  the 
epithelium  of  the  glands  are  found  in  the  discharge  (Schroeder).  The 
secretion  is  at  first  serous,  then  purulent. 

In  chronic  endometritis,  the  mucous  membrane  is  hypertrophied  and 
marked  with  patches  of  old  extravasation. 

The  microscopic  appearances  have  only  of  recent  years  been  worked 
tnere  1S  considerable  difference  of  opinion  both  as  to  the  changes 
produced  and  the  significance  of  them.  To  understand  these,  we  must 
keep  in  mind  the  two  essential  elements  of  the  mucous  membrane — the 
glands  and  the  inter-glandular  tissue  ;  and  also  the  view  of  Leopold, 


FIG.  192. 

CROSS  SECTION  or  A  GRANULATION  IN  A  CASE  OF  ENDOMETRITIS  (De  Si'iieti/).    1.  Stroma  ;  2.  Dilated 

(V) 


who  considers  the  inter-glandular  tissue  as  made  up  chiefly  of  lym- 
phatics. 

Accordingly,  as  the  changes  affect  principally  one  or  other  of  the  two 
elements  of  the  mucous  membrane,  Ruge  *  finds  a  glandular,  an  inter- 
stitial, and  a  mixed  form — the  last  being  a  combination  of  the  first  two. 

In  the  glandular,  a  marked  growth  and  increase  of  the  glandular 
epithelium  occurs.  The  gland-ducts  hypertrophy  (PI.  XIII.  fig.  3), 
and  through  multiplication  of  the  epithelium  may  have  bulgings  of  it 
into  their  lumina,  making  them  saw -like  instead  of  tubular  in  section,  or 
the  wall  may  be  thrown  into  folds  (cf.  appearance  of  normal  glands 
PL  XIII.  fig.  1  with  PL  XIII.  fig.  3).  In  addition  to  hypertrophy 
there  may  be  hyperplasia  (PL  XIII.  fig.  4),  the  glands  increasing  in 
number  either  through  lateral  branching  or  the  ingrowth  of  new  ones 
from  the  surface.  In  the  interstitial  (PL  XIII.  fig.  2),  the  stroma  is  affected 
— in  recent  cases  its  cells,  in  more  chronic  the  intercellular  substance.  In 

1  Schroeder — op.  cit.  S.  112. 


PLATE  XIII. 


Stellate  corpuscles 

of  interglandular 

tissue. 


Epithelium 
of  glands. 


MUCOUS  MEMBEANE  OF   UTERUS  IN  ENDOMETBITIS 
(Fios.  1—5,  Ruge;  FIG.  6,  Heinriciut). 

FIG.  1.  Normal  Mucous  Membrane,  FIG.  2.  Interstitial  Endometritis, 
FIG.  3.  Glandular  hypertrophic  E.,  FIG.  4.  Glandular  hyperplastic  E.  (all  magnified  ten  times). 

FIG.  5.  Endometritis  after  abortion  showing  group  of  decidual  cells  d  c 
FIG.  6.  From  E.  fungosa  showing  nature  of  changes  in  interglandular  tissue  (v.  p.  318). 


ENDOMETRITIS.  317 

the  recent  cases,  there  are  abundance  of  small  cells  (like  nuclei  only 
from  the  small  quantity  of  their  protoplasm),  which,  if  recovery  does 
not  take  place,  pass  into  spindle-cells  arranged  in  interlacing  bands; 
sometimes,  they  swell  up  and  take  on  a  decidual  character — the  nuclei 
becoming  larger  and  containing  nucleoli.  In  the  chronic  cases,  the  inter- 
cellular substance  is  thickened  by  exudation  and  its  fibres  increased  and 
thickened. 

In  Endometritis  after  abortion,  small  islands  of  decidual  cells  (which 
have  not  undergone  retrograde  changes  as  rapidly  as  the  rest  of  the 
decidua)  are  sometimes  found  with  small-celled  proliferation  going  on 
round  them  (PI.  XIII.  fig.  5). 

A  special  form  of  Endometritis  was  carefully  described  by  Olshausen  oishausen's 
under  the  name  of  E.  fungosa.     In  it  the  mucous  membrane  is  hyper- ^j0016' 
trophied  to  three  or  four  times  its  normal  thickness.     It  is  elevated  Fungosa. 
through  its  whole  extent  in  a  soft  cushion-like  swelling,  or  in  more 


FIG.  193. 

VASCULAR  TYPE  OF  ENDOMETRITIS — Endometritis  fungosa  (Olthausen). 

localised  spongy  masses  ;  the  hypertrophy  does  not  extend  beyond  the 
os  internum  to  the  cervix,  and  thus  resembles  in  its  situation  a  decidual 
membrane.  The  portions  removed  by  the  curette  are  unusually  thick  ; 
one  side  presents  a  smooth  rose-coloured  surface  which  resembles  the 
appearance  of  the  mucous  membrane  of  the  intestine,  and  the  other  has 
a  deep-red  raw-surface.  "  The  microscopic  examination  of  these  scrap- 
ings," Olshausen  says,  "shows  that  there  is  great  hypertrophy  of  the 
mucous  membrane  with  increase  of  all  its  elements — moderate  dilatation 
of  the  lumina  of  the  glands,  enlargement  of  the  blood-vessels,  and 
marked  cellular  infiltration  of  the  connective  tissue  "  (fig.  193).  The 
characteristics  of  this  type  are,  that  the  glands  do  not  become  enlarged 
so  as  to  produce  cystic  dilatations,  and  that  the  blood-vessels  are  greatly 
distended ;  the  latter  fact  explains  the  haemorrhage  which  is  the  chief 
symptom.  De  Sinety  gives  a  figure  which  shows  the  dilatation  of  the 
blood-vessels  in  this  vascular  type  of  Endometritis  (fig.  194). 


318 


AFFECTIONS   OF   UTERUS. 


In  some  cases  of  Endometritis  fungosa,  Zeller  found  that  portions  of 
the  exfoliated  mucous  membrane  consisted  of  squamous  epithelium 
arranged  in  several  layers  —  a  sort  of  psoriasis  uterina.  This  shows 
that  columnar  epithelium  may  change  into  squamous,  a  fact  of  great 
interest  with  regard  to  the  changes  in  catarrhal  patches  described  in 
the  preceding  chapter. 

Heinricius'  Heinricius  has  recently  described  the  scrapings  taken  from  a  large 
Endome-  n^mber  of  cases  of  fungous  endometritis.  A  thin  section,  with  sparing 
tritis  infiltration  give  under  ahigh  power1  the  appearance  seen  in  PI.  XIII.  fig.  6. 
stroma  between  the  glands  (the  epithelium  of  which  is  seen  in  the 


corners  of  the  section)  consists  of  a  basis  of  stellate  corpuscles  with 


FIG.  194. 

CROSS  SECTION  OF  GRANULATION  COMPOSED  OF  DILATED  VESSELS  IN  A  CASE  OF  ENDOMETRITIS  (-4r°-). 
1.  Vessels  cut  longitudinally ;  2.  Vessels  cut  transversely  ;  3.  Dilated  vessel  filled  with  blood 
corpuscles  ;  4.  Embryonic  tissue  (De  Sinity). 


anastomosing  processes  upon  and  between  which  lie  two  varieties  of  cells — 
large,  oval,  faintly  stained  ones,  and  others,  small,  round,  and  deeply 
stained,  the  former  being  the  nuclei  of  an  endothelium,  the  latter  lymph 
corpuscles.  He  thus  agrees  with  Leopold  that  the  interstitial  tissue 
consists  largely  of  lymph  sinuses.  When  inflammation  occurs,  the  lymph 
corpuscles  and  those  of  the  endothelium  proliferate  and  produce  an 
appearance  resembling  a  "  small-celled  infiltration,"  for  the  basal  net- 
work is  obscured  by  them.  He  thus  comes  round  to  practically  the 
same  condition  as  Olshausen  has  described,  but  assigns  a  different  position 
to  the  small  cells. 

Landau  and  Abel2  deny  the  existence  of  a  hyperplastic  glandular  form  of  Endometritis 
and  would  recognise  only  the  E.  fungosa,  making  the  cases  of  hypertrophied  glands  a 
localised  Adenoma  simplex.  Their  argument  is  that  the  changes  in  any  inflammation 

1  Zeiss,  Ocular  3,  Water  immersion  K. 

2  Beitnige  zur  pathologischen  Anatomic  des  Endometrium  :  Archiv  f.  Gyn.,  XXXIV.,  S.  165. 


ENDOMETRITIS. 


319 


are  primarily  in  the  interglaridular  tissue,  the  changes  in  the  epithelium  of  the  glands 
being  so  to  speak  accidental  and  the  result  of  the  hyperaemia.  The  "cork-screw-like 
hypertrophy  "  is  a  normal  condition.  Where  the  glands  actually  grow,  it  is  an  Adenoma. 
Further,  as  to  the  interglandular  changes,  the  decidual  cells  described  by  Huge  are  not 
peculiar  to  the  uterus,  but  simply  the  large  epithelial  cells  (fibro-blasts)  which  are  an 
intermediate  stage  in  the  formation  of  connective  tissue  from  inflammatory  products  in 
any  situation. 

Another  form  of  Endometritis  is  described  by  De  Sinety.  "In  other Villous or 
cases,"  he  says,  "the  vegetations  are  specially  constituted  of  embryonic f^m  o/y 
tissue  with  few  blood-vessels.  There  are  only  traces  of  the  glands  andEndome- 
some  remains  of  more  or  less  degenerated  epithelium.  We  have  to  do 
with  a  truly  inflammatory  tissue  comparable  to  that  which  forms  upon 
an  exposed  wound.  At  certain  points  there  are  islands  of  degenerated 
elements  which  are  not  coloured  by  reagents  and  are  analogous  to  those 
observed  in  foci  producing  pus.  The  degeneration  of  embryonic  elements 


tritis. 


FIG.  195. 

CROSS  SECTION  OF  GRANULATION  COMPOSED  OF  EMBRYONIC  ELEMENTS,  FROM  A  CASE  OF  ENDO- 
METRITIS.    1.  Embryonic  tissue  ;  2.  Part  undergoing  fatty  degeneration  (De  Sinet 


explains  to  us  the  abundance  of  the  muco-purulent  discharge  observed 
during  life"  (fig.  195).  Slavjansky  also  has  described  a  villous  or 
papillary  form  of  endometritis  in  which  the  mucous  membrane  has 
lost  its  epithelial  covering  and  has  its  inner  layer  composed  of  embryonic 
connective  tissue. 

When  chronic  Endometritis  has  persisted  for  a  long  time,  the  mucous  Ultima 
membrane  becomes  atrophied;  the  ciliated  and  afterwards  the  cylindri-g^^g.1 
cal  epithelium  is  lost,  and  sm  all  polymorphous  cells  resembling  squamous  tritis. 
epithelium  take  their  place  ;  finally,  the  mucous  membrane  disappears 
altogether  and  the  uterine  cavity  conies  to  be   lined  with  a  layer  of 
connective  tissue.     The  glands  fall  out  so  that  the  mucous  membrane 
becomes  mesh-like,  or  they  are  constricted  to  form  retention  cysts. 

Senile  atresia  of  the  cervical  canal  is  the  result  of  a  localised  chronic  |,en,ile 
Endometritis.  This  is  one  of  the  physiological  changes  which  occur  tritis. 
after  the  menopause.  In  some  cases,  however,  it  becomes  pathological  ; 


320  AFFECTIONS  OF  UTERUS. 

accumulation  of  mucus,  more  rarely  of  blood,  takes  place   above   the 
obstruction. 

Heitz-  Approaching   Endometritis   from   a   clinical   standpoint,   Heitzmami 

dass?fica-  classifies  its  various  forms  as  follows.  Taking  Hypersecretion, 
tionof  Haemorrhage,  and  Pain,  he  forms  three  groups  according  as  one  of 
tritis.  these  is  the  prominent  symptom.  In  the  first  group  (with  Hyper- 
secretion)  there  is  a  catarrhal  and  a  gonorrhceal  form.  In  the  second 
(with  Haemorrhage),  we  have  (1)  a  diffuse  hypertrophic,  the  mucous 
membrane  resembling  that  just  before  menstruation,  the  pathological 
changes  being  interstitial,  and  goblet-cells1  in  the  secretion  being 
characteristic ;  (2)  a  papillary,  referred  to  above  as  described  by  Slav- 
jansky,  and  probably  also  by  De  Sinety ;  (3)  endometritis  fungosa,  of 
Olshausen ;  (4)  e.  polyposa,  a  rare  form  described  by  Klebs,  in  which 
the  mucous  membrane  was  elevated  in  transverse  ridges,  and  large 
stellate  cells  and  dilated  lymphatics  were  found  in  the  stroma ;  (5)  e. 
deddualis,  which  includes  cases  occurring  after  abortion.  In  the  third 
group  (with  Pain)  there  are  three  forms :  e.  dysmenorrkoica,  with  Pain 
only ;  e.  exfoliativa,  with,  in  addition,  the  discharge  of  a  dysmenorrhceal 
membrane  ;  and  e.  dissecans,  a  rare  form  described  by  Kubassow,  in  which 
muscular  tissue  as  well  as  mucous  membrane  is  separated  and  expelled 
with  severe  symptoms.  This  last  group  will  be  considered  under  the 
chapter  on  Dysmenorrhcea.  In  addition  to  these  three  groups,  he  adds  an 
atrophic  form  which  is  physiological  and  occurs  after  the  menopause. 

In  summing  up  the  facts  as  to  the  pathology  of  Endometritis,  we  find 
that  Ruge  describes  changes  sometimes  specially  affecting  the  glands, 
sometimes  the  interglandular  tissue  ;  that  Olshausen  and  Heinricius, 
directing  their  attention  to  a  special  form  in  which  the  mucous  mem- 
brane is  spongy  and  bleeds  freely  at  the  menstrual  period,  describe 
changes  chiefly  interstitial ;  that  De  Sinety  and  Slavjansky  make  a 
third  type  in  which  a  granulation  tissue  is  produced  in  the  uterus ;  and 
that  Heitzmann,  approaching  the  subject  from  an  entirely  different  stand- 
point, groups  isolated  forms  according  to  their  leading  symptom. 

A  clinical  classification  would  be  the  best  were  we  sure  of  our  ground, 
but  proof  is  yet  wanting  that  there  is  increased  secretion  from  the  uterine 
glands,2  for  Leucorrhoea  may,  as  far  as  we  know,  be  always  cervical 
in  origin.  Pain,  also,  may  not  be  connected  with  changes  in  the 
uterine  mucous  membrane.  Haemorrhage  is  the  only  symptom  by 
which,  without  doubt,  Endometritis  shows  itself. 

A  pathological  classification  is  what  we  must  aim  at,  but  it  will  be  a 
long  time  before  such  an  one  will  be  established.  Bits  of  tissue  removed 
by  the  curette  are  very  unsatisfactory  materials  for  working  out  the 

1  See  another  paper  by  him  on  the  "Changes  in  the  Epithelium  in  Endometritis : "  Wien.  med. 
Jahrbiicher,  Dec.  1885. 

1  There  is  such  a  condition  as  hyperplasia  of  the  glands,  but  an  adenoma  does  not  imply  increased 
gecretion. 


ENDOMETRITIS.  321 

nature  of  a  pathological  process,  however  important  their  examination 
may  be  for  differential  diagnosis.  The  physiological  changes  in  the 
uterine  mucous  membrane  connected  with  menstruation  (see  Chap.  VII.) 
are  a  disturbing  factor.  A  scraping  immediately  before  the  period  will 
give  quite  a  different  appearance  from  that  just  after. 

ETIOLOGY. 

Acute  endometritis  is  a  rare  condition,  and  never  occurs  before  puberty. 
It  comes  on  most  frequently  in  connection  with  menstruation,  when  the 
physiological  congestion  readily  passes  into  inflammation.  It  is  occa- 
sioned by  exposure  to  cold  or  sexual  excess  at  the  periods,  and  by  the 
extension  of  gonorrhooal  inflammation  from  the  mucous  membrane  of 
the  vagina.  It  also  occurs  in  the  exanthemata,  typhus,  scarlet  fever, 
and  measles ;  it  has  further  been  observed  in  cholera  (Slavjansky],  and 
in  certain  cases  of  phosphorus  poisoning.  In  puerperal  inflammation, 
endometritis  is  of  course  present. 

Chronic  endometritis  is  occasionally  the  result  of  acute ;  most  fre- 
quently, however,  it  arises  independently.  Sometimes  it  is  merely  the 
indication  of  the  constitutional  state  ;  in  scrofulous  and  chlorotic  cases, 
the  normal  leucorrhoea  (which  precedes  and  follows  menstruation)  is 
increased  in  quantity  and  prolonged  during  the  intermenstrual  period. 
This  is  due  to  hypersecretion  rather  than  to  inflammation.  Increased 
leucorrhcea,  with  diminished  menstrual  flow,  is  quite  characteristic  in 
phthisis. 

Chronic     endometritis    arises    independently    from    the     following  Causes  of 
causes:-  <*£?« 

Parturition,  specially  when  the  uterus  has  not  been  completely m( 

emptied ; 

Exposure  to  cold  during  menstruation ; 
Polypi  or  other  tumours  in  the  uterine  cavity ; 
Direct  injury  through  incautious  use  of  sound  or  tent ; 
Extension  of  gonorrhceal  or  simple  inflammation  from  vagina  and 

cervix. 
It  has  also  been  found  after  non-physiological  amenorrhcea. 

Of  these  the  most  important  are  parturition  and  displacements. 

As  regards  parturition,  endometritis  is  frequent  after  abortion ; 
usually  this  is  due  to  the  patient's  rising  too  soon,  or  to  the  incomplete 
emptying  of  the  uterus.  Kiistner  has  traced  the  transition  of  a  portion 
of  decidua,  retained  after  abortion,  into  a  tissue  having  the  structure  of 
a  mucous  polypus.  As  to  the  frequency  of  this  occurrence,  he  says  that, 
of  1 1 2  cases  of  endometritis,  9  were  cases  of  deciduoma.  After  full-time 
labour,  the  seat  of  the  placenta  seems  to  be  in  many  cases  the  starting- 
point  of  the  inflammatory  process. 
x 


322  AFFECTIONS  OF   UTERUS. 

Uterine  displacements  do  not  necessarily  produce  endometritis.  We 
sometimes  find  a  retroversion  or  retroflexion  which  has  produced  no 
symptoms.  As  a  rule,  chronic  inflammation  of  the  endometrium,  as  well 
as  of  the  muscular  coat,  results  from  passive  congestion. 

Brennecke l  and,  more  recently,  Heinricius  2  have  drawn  attention  to 
the  occurrence  of  eudometritis  following  non-physiological  amenorrhcea. 
After  irregular  menstruation  (at  longer  or  shorter  intervals),  or  complete 
amenorrhcea,  profuse  bleeding  takes  place  from  the  uterus.  It  is  most 
common  in  patients  towards  the  menopause,  but  has  also  occurred  in 
ansemic  or  poorly  nourished  girls.  They  ascribe  it  to  lowered  activity 
of  the  ovaries  so  that  the  hypersemia  at  the  menstrual  period  leads  only 
to  hyperplasia  of  the  uterine  mucous  membrane,  not  to  hsemorrhage ; 
hence  the  mucous  membrane  becomes  hyperplastic,  and  when  haemor- 
rhage does  return  it  is  profuse. 

SYMPTOMS. 
A.  Of  Acute  Endometritis. 

These  are  fever  more  or  less  severe,  according  to  the  inflammation, 
pain  in  the  back  and  lower  part  of  the  abdomen  with  the  sensation  of 
weight  in  the  pelvis,  and  in  severe  cases  vesical  and  rectal  tenesmus. 
The  characteristic  symptom  is  the  discharge,  which  is  at  first  clear  and 
watery  but  after  a  few  days  becomes  creamy  and  purulent.  The  men- 
strual flow  is  sometimes  suppressed,  rarely  is  it  increased. 

B.  Of  Chronic  Endometritis. 
The  symptoms  usually  given  are  the  following : — 

Menorrhagia ; 

Leucorrhoea ; 

Dysmenorrhosa ; 

Weakness  in  the  back ; 

Pain  in  pelvis  and  loins  ; 

Digestive  derangements ; 

Sterility ; 

Abortion. 

Menorrhagia  is  the  characteristic  symptom,  and  may  become  serious 
from  the  anaemia  which  it  produces.  It  shows  itself  first  in  increased 
duration  of  the  menstrual  flow,  which  becomes  gradually  prolonged  over 
the  intermenstrual  period  till  the  loss  of  blood  becomes  continuous. 
Dysmenorrhcea  is  frequently  present,  but  it  is  more  probably  due  to 
complications  (e.g.,  flexions  or  chronic  metritis  than  to  the  condition  of 
the  mucous  membrane).  Membranous  dysmenorrhcea  (accompanied  with 
exfoliation  of  the  mucous  membrane  at  the  menstrual  period)  might  be 

'  Archiv  f.  Gyn.  XX.  S.  455.  *  Op.  cit. 


ENDOMETRITIS.  323 

considered  here,  as  its  pathology  is  most  nearly  allied  to  endometritis ; 
from  its  peculiar  symptoms,  however,  it  is  better  to  consider  it  in  the 
chapter  on  Dysmenorrhoea  (Section  VIII.). 

Leucorrhcea1  is  a  frequent  symptom.  The  secretion  from  the  body 
of  the  uterus  is  of  a  watery  character,  less  dense  and  gelatinous 
than  that  from  the  cervix ;  usually,  however,  there  is  cervical  catarrh 
as  well.  The  uterine  secretion  has  an  alkaline  reaction,  while  vaginal 
leucorrhcea  is  acid.  Sometimes  it  is  tinged  with  blood,  producing  an 
appearance  which  Bennet  compared  to  the  rust-coloured  sputum  in 
pneumonia.  The  blood-stained  leucorrhoea  must  not  be  confounded 
with  the  menstrual  flow.  In  some  cases  the  discharge  is  purulent, 
accumulates  in  the  uterine  cavity,  and  is  only  discharged  at  intervals. 

"  Weakness  in  the  back"  is  the  common  complaint  made  by  the 
patient.  It  may  amount  to  actual  pain,  but  more  generally  it  shows 
itself  as  feebleness  or  weariness  which  incapacitates  the  patient  for  her 
daily  work. 

Derangements  of  the  digestive  and  nervous  systems  invariably  follow 
when  the  disease  has  become  chronic.  There  is  impaired  digestion 
with  loss  of  appetite,  and,  as  the  result,  general  debility.  Whether 
these  are  due  to  the  drain  on  the  system  produced  by  the  leucorrhoea 
or  to  the  close  connection  between  the  nervous  centres  for  the  sexual 
organs  and  those  for  the  digestive  apparatus,  we  do  not  know.  Derange- 
ments of  the  nervous  system  show  themselves  in  frontal  headache  and 
depression  of  spirits  amounting  sometimes  to  melancholia. 

Ancemia,  with  its  characteristic  train  of  symptoms,  is  the  leading 
symptom  in  the  haemorrhagic  type  (Olshausen). 

Sterility  is  frequently  present,  and  has  been  in  certain  cases  the 
only  symptom  complained  of.  The  secretion  may  destroy  spermatozoa, 
may  mechanically  prevent  them  from  passing  upwards,  or  the  villi  of 
the  fertilised  ovum  may  be  prevented  from  finding  an  attachment  in 
the  diseased  mucous  membrane.  Again,  the  ovum  is  attached  for  a 
time  but,  from  the  imperfect  formation  of  the  uterine  portion  of  the 
placenta,  abortion  takes  place ;  repeated  abortion  is  characteristic  in 
chronic  endometritis.  A  vicious  circle  is  thus  produced :  as  men- 
tioned under  etiology,  endometritis  frequently  follows  abortion ;  abor- 
tion, in  its  turn,  frequently  follows  endometritis. 

PHYSICAL  SIGNS. 

A.   Of  Acute  Endometritis. 

There  is  tenderness  on  pressure  over  the  lower  part  of  the  abdomen 
due  to  peritonitis  which  generally  accompanies  the  acute  form.  On 
vaginal  examination  the  cervix  is  found  to  be  swollen  and  puffy,  the  os 

1  We  mention  this  as  a  symptom  usually  given,  although  proof  is  wanted  that  the  secretion  from 
the  uterine  mucosa  is  increased  in  Endometritis — it  may  be  entirely  cervical. 


324  AFFECTIONS  OF  UTERUS. 

is  dilated  and  feels  velvety  from  eversion  of  the  mucous  membrane, 
the  Bimanual  is  unsatisfactory  from  sensitiveness  to  pressure.  The 
speculum  shows  the  vaginal  portion  to  be  congested,  with  catarrhal 
patches  round  the  os  and  the  follicles  enlarged  and  sometimes  contain- 
ing pus.  The  leucorrhoeal  discharge  already  described  is  seen  coming 
from  the  os  uteri.  The  sound  should  not  be  used,  as  its  introduction 
causes  pain  and  sometimes  haemorrhage. 

B.   Of  Chronic  Endometritis. 

Tenderness  on  pressure  is  not  necessarily  present,  though  we 
frequently  find  it  as  the  result  of  complications — peritonitis,  cellulitis, 
ovaritis. 

On  vaginal  examination  the  vaginal  portion  of  the  cervix  is  normal, 
or  has  the  characters  described  under  cervical  catarrh.  The  Bimanual 
shows  the  uterus  to  be  enlarged ;  it  is  soft  and  flabby  so  that  its  form 
cannot  easily  be  made  out,  or  of  a  firm  consistence  from  chronic 
metritis. 

The  sound  passes  beyond  the  2i-inch  knob  to  a  varying  extent,  and 
on  withdrawal  is  frequently  tinged  with  blood.  Its  introduction  may 
be  difficult  from  irregularities  in  the  mucous  membrane,  and  is  some- 
times painful.  In  some  cases  pain  is  complained  of  Avhen  the  sound 
touches  the  fundus  of  the  uterus,  which  some  consider  characteristic 
of  endometritis.  Routh  has  described  a  variety  of  the  disease  under 
the  name  "Fundal  Endometritis,"  in  which  this  is  prominent:  on 
forcible  pressure  of  the  sound  against  the  fundus  "  absolute  agony  may 
result,  which  may  produce  vomiting,  an  hysterical  faint  or  fit,  some- 
times a  regular  epileptic  fit."  The  sound  is  most  useful  in  demon- 
strating irregularities  of  the  mucous  membrane,  and  their  recognition  is 
of  great  importance  :  to  detect  these  the  sound  is  held  lightly  between 
the  finger  and  thumb  and  moved  slowly  backwards  and  forwards  over 
the  mucous  membrane ;  a  grating  or  catching  sensation  is  felt  when 
they  are  present.  We  must  note,  however,  as  Olshausen  points  out, 
that  the  spongy  irregularities  may  escape  detection  by  the  sound. 

In  the  speculum  we  see,  issuing  from  the  os,  the  leucorrhoeal  dis- 
charge with  the  characteristics  given  above  ;  usually  it  is  mixed  with 
that  from  the  cervix.  The  appearances  described  under  cervical  catarrh 
are  also  frequently  present. 

DIAGNOSIS  :    DIFFERENTIAL    DIAGNOSIS. 

Value  of  The  curette  is  invaluable  in  diagnosis,  especially  when  its  use  is 
followed  by  microscopical  examination  of  the  scrapings — the  importance 
of  which  here  cannot  be  overrated. 

This  throws  light  on  the  etiological  question,  whether  the  endomet- 
ritis be  due  to  incomplete  emptying  of  the  uterus  after  parturition  ? 


ENDOMETRITIS.  325 

In  such  a  case  we  find  among  the  scrapings  large  decidual  cells  or 
fragments  of  the  villi  of  the  chorion  in  a  state  of  fatty  degeneration. 

It  enables  us  to  differentiate  endometritis  from  commencing  malig- 
nant disease — carcinoma  and  sarcoma.  In  carcinoma  we  see  under  the 
microscope  abundance  of  epithelial  cells  of  irregular  form  and  with 
many  nuclei  (v.  fig.  285).  In  sarcoma  we  see  under  the  microscope 
the  typical  round  or  spindle-shaped  cells.  The  hsemorrhagic  type  of 
endometritis  may  readily  be  mistaken  for  sarcoma  uteri,  because  "it 
spreads  in  a  diffuse  manner,  pre-eminently  causes  haemorrhage,  pro- 
duces pain  not  at  all  or  only  late"  (Olshausen).  The  microscope, 
however,  settles  the  diagnosis.  Care  must  be  taken  not  to  mistake 
the  small-celled  infiltration  of  the  tissue  (fig.  193)  for  round-celled 
sarcoma.  The  cells  of  the  latter  are  characterised  by  their  larger  size 
and  oval  nuclei  (v.  figs.  301  and  302). 

PROGNOSIS. 

Endometritis  is  not  a  fatal  disease  in  itself,  though,  when  long  pro- 
tracted, it  seriously  affects  the  constitution  and  produces  permanent  ill- 
health.  In  cases  of  excessive  haemorrhage,  the  condition  becomes  grave. 

The  treatment  is  often  protracted,  and  the  patient  should  always  be 
warned  of  this.  The  occurrence  of  conception  will  produce  the  most 
favourable  conditions ;  and,  if  due  care  be  taken  to  prevent  abortion 
in  the  early  months,  and  in  the  management  of  the  puerperioim,  we  may 
hope  for  a  cure. 

When  endometritis  is  associated  with  a  strumous,  tubercular,  or 
syphilitic  diathesis,  it  may  baffle  all  our  efforts. 

TREATMENT. 

A.   Of  Acute  Endometritis. 

Rest   in   bed,  warm  fomentations  over  the  abdomen,  and  the  free  Treatment 
use  of  opium  if  there  is  much  pain,  form  all  the  treatment  required.  Endome- 
Should  the  bowels  not  be  moved  freely  before  the  attack,  castor  oiltritis. 
writh   an   enema   should   be   given    since   the    loaded   rectum   presses 
injuriously  on  the  inflamed  uterus.     Should  the  bowels  not  be  loaded, 
the  patient  is  not  to  be  troubled  with  purgatives  but  rather  kept  under 
the  influence  of  opium.     If  there  is  menorrhagia,  ergot  is  required ; 
when  the  discharge  is  free,  it  is  to  be  given  hypodermically.     Warm 
water  injections  should  not  be  used  until  the  acute  stage  is  passed, 
the   pain   and   other   signs   of  inflammation   have   subsided,  and   the 
leucorrhcea  is  abundant. 

B.  Of  Chronic  Endometritis. 

Prophylactic  treatment  is  of  great  importance.  A  patient  who  is 
subject  to  endometritis  should  guard  against  exposure  during  thetritis. 


326  AFFECTIONS  OF  UTERUS. 

menstrual  period.  When  conception  takes  place,  the  practitioner  should 
remember  the  liability  to  abortion,  the  importance  of  seeing  that  the 
uterus  be  thoroughly  emptied  after  parturition,  and  that  the  patient 
take  proper  care  during  the  puerperium ;  in  the  latter  period,  ergot  is 
beneficial. 

We  begin  with  hot-water  injections,  and  the  administration  of  ergot ; 
this  is  given  as  the  liquid  extract  (twenty  drops  in  water  three  times 
a  day,  increased  to  thirty  at  the  menstrual  period)  or  ergotin — four 
grains  in  pill,  daily. 

If  the  uterine  cavity  be  enlarged  so  that  the  sound  moves  freely  within 
it,  if  there  be  roughness  of  the  endometrium,  or  if  there  has  been  a 
Curetting  recent  miscarriage  or  confinement,  we  employ  the  curette  folloived  by  the 
application  of  carbolic  acid.  In  the  last  class  of  cases  the  cause  of  the 
endometritis  has  been  the  incomplete  separation  of  the  placental  villi ; 
if  treated  while  still  recent,  such  cases  furnish  the  most  satisfactory 
instances  of  an  immediate  and  complete  cure. 

Curetting  should  not  be  performed  while  active  cellulitis  or  peritonitis 


FIG.  196. 

SOUND  DKESSED  WITH  WADDING  FOR  THE  APPLICATION  OF  CARBOLIC  ACID. 

is  present.  The  fixing  of  the  uterus  by  adhesions  or  cicatrisation  does 
not  contra-indicate  the  operation,  though  these  render  it  more  difficult 
through  preventing  the  uterus  from  being  drawn  down  by  the  volsella; 
when  they  are  present,  undue  traction  must  not  be  made.  The  time 
selected  for  operation  is  a  week  after  a  menstrual  period ;  when  the  dis- 
charge is  continuous,  the  period  is  indicated  by  increase  in  amount. 

Curetting  of  the  Uterus  with  application  of  Carbolic  Acid.     The  follow- 
ing instruments  are  necessary  : — 

Sims'  or  Battey's  speculum, 

Three  or  four  sounds  dressed  with  cotton  wool, 

Volsella, 

Curette, 

Crystals  of  carbolic  acid  liquefied, 

Cotton  wadding  and  glycerine, 

Mackintosh. 
Chloroform  is  not  necessary  unless  the  patient  be  nervous. 


ENDOMETRITIS. 


327 


The  sounds  should  be  covered  with  a  thin  layer  of  cotton  wool,  extend- 
ing almost  to  the  knob  (fig.  196).  The  sound  is  dressed  as  follows  : — A 
film  of  cotton  wadding  is  laid  on  the  palm  of  the  left  hand,  the  last  two 
and  a  half  inches  of  the  sound  are  moistened  and  pressed  firmly  on  the 
cotton  wadding,  the  left  hand  is  closed  over  it,  the  sound  is  turned  twice 
or  thrice  round  within  the  shut  hand  till  the  cotton  wadding  becomes 
tightly  rolled  on.  The  dressing  must  bite  the  sound  firmly  so  that  it 
may  not  come  off  within  the  uterine  cavity,  and  must  not  be  too  thick 


FIG.  197. 

UTERUS  DRAWN  DOWN  WITH  THE  VOLSELLA  AND  CURETTE  IN  POSITION.    The  speculum  is  held  and 
the  labium  drawn  upwards  by  an  assistant.     The  operator's  hands  are  crossed  {A.  R.  Simpson). 

to  be  easily  carried  in.     To  remove  the  cotton  wadding  afterwards,  the 
dressing  is  unrolled  under  water. 

Thomas'  dull-wire  cm-ette  (fig.  100)  has  the  advantage  of  being,  from 
its  small  size,  easily  passed ;  but  it  is  not  strong  enough,  so  that  the 
steel  curette  is  preferable — Martin's  (fig.  101)  being  the  best.  The 
crystals  of  carbolic  acid  are  kept  in  stoppered  bottles,  at  the  ordinary 
temperature  a  portion  remains  liquid ;  tincture  of  iodine,  strong  nitric 
acid,  or  chromic  acid  may  be  substituted  for  it. 


328 


AFFECTIONS  OF  UTERUS. 


The  patient  is  placed  semiprone  ;  Sims'  speculum  is  passed  and  held 
by  an  assistant  who  with  the  left  hand  draws  back  the  upper  labium 
(fig.  197)  —  if  there  be  no  assistant,  some  form  of  self  -  retaining 
speculum  is  used ;  the  vagina  is  washed  out  with  carbolised  water.  The 
anterior  lip  is  laid  hold  of  with  the  volsella  and  drawn  downwards,  the 
volsella  being  steadied  with  the  fingers  of  the  left  hand ;  the  curette  is 
taken  in  the  right  hand,  dipped  in  carbolised  oil  (1-20),  and  carried  into 
the  uterine  cavity  (fig.  197).  The  anterior  wall  of  the  uterus  is  first 
scraped  from  the  fundus  downwards  ;  only  slight  pressure  on  the  instru- 
ment is  made,  unless  it  be  felt  to  slip  over  the  irregularities  of  the 
mucous  membrane  without  removing  them  ;  the  detached  fragments  are 
brought  down  to  the  cervix  with  a  raking  motion,  and  set  aside  for 
microscopical  examination  :  the  posterior  wall  is  scraped  in  the  same 
way.  A  sound,  dressed  with  dry  cotton  wadding,  is  passed  to  clear 
away  the  blood  and  mucus ;  the  same  process  is  immediately  repeated 
with  a  second,  and  with  a  third  if  necessary.  A  reserve  sound,  pre- 
viously dipped  in  the  carbolic  acid  so  as  to  be  ready  for  use,  is  carried  in 
immediately  after  the  last  of  these  has  been  withdrawn  ;  if  there  is  much 
bleeding  or  the  uterine  cavity  is  large,  a  second  application  should  be 


n). 


made  ;  our  aim  is  to  apply  the  carbolic  acid  to  the  whole  of  the  raw 
surface,  without  its  being  diluted  with  blood  or  mucus.  The  volsella 
being  withdrawn,  a  pledget  of  cotton  wadding  soaked  in  glycerine  is 
placed  in  the  upper  part  of  the  vagina  so  as  to  embrace  the  cervix ;  this 
prevents  the  carbolic  acid  from  running  down  into  the  vagina. 

The  patient  keeps  her  bed  for  a  week  after  the  operation,  the  pledget 
having  been  removed  on  the  second  day.  Special  care  should  be  taken 
at  the  next  menstrual  period. 

Doleris  *  has  recently  insisted  on  the  advantage  of  carbolic  acid 
above  all  other  applications  to  the  endometrium,  because  while  it 
destroys  thoroughly  diseased  tissue  it  does  not  leave  a  slough.  It  also 
soaks  further  in  than  strong  acids  which  coagulate  the  albumen  and 
have  only  an  action  limited  to  what  they  touch. 

Applications  without  a  previous  curetting  may  be  made  in  cases  where 
there  is  no  history  of  recent  parturition  or  where  the  symptoms 
(menorrhagia)  are  slight.  In  all  other  cases  the  preliminary  use  of 

'_  He  'uses  a  solution  1  in  2  or  3  of  glycerine,  and  mentions  three  hundred  and  thirty-nine  cases 
which  he  has  treated  by  the  application  of  carbolic  acid  alone  or  by  curetting  followed  by  carbolic 
acid,  with  very  satisfactory  results.  Op.  cit.,  p.  195. 


ENDOMETRITIS.  329 

the  curette  is  a  distinct  advantage,  as  it  removes  the  fungosities  and 
thus  allows  the  caustic  to  act  more  efficiently.  Iodised  phenol,1  intro- 
duced by  Battey,  is  a  very  useful  and  safe  application. 

Atthill  advocates  the  use  of  strong  nitric  acid,  and  the  preliminary  Atthill's 
dilatation  of  the  cervix  with  tents  so  as  to  allow  a  thicker  dressing  of  the 
sound  and  more  abundant  application  of  the  acid.     He  uses  an  intra- 
uterine  speculum  of  vulcanite  which  is  passed  within  the  cervix ;  this 
prevents  the  acid  from  acting  on  the  cervical  canal. 

The  application  may  be  made  in  a  solid  form,  of  which  the  best  is  Solid 
nitrate  of  silver.  This  is  employed  as  follows:  the  nitrate  of  silver  istions. 
fused  in  a  watch-glass  over  a  spirit  flame  ;  a  probe  with  a  roughened  end 
is  dipped  in  this  and  the  film  allowed  to  cool,  and  then  dipped  again 
repeatedly  till  several  layers  are  deposited.2  Sir  James  Simpson  applied 
the  nitrate  of  silver  in  powder  on  the  porte  caustique  represented  at 
fig.  198.  The  simplest  way  is  to  carry  an  ordinary  quill  with  a  nitrate 
of  silver  point  into  the  cavity  of  the  uterus ;  it  may  be  passed  in  and 
withdrawn  again,  or  held  there  till  the  point  melts  off;  Crede  of  Leipsic 
has  got  very  good  results  from  this  mode  of  treatment.  Barnes  has 
devised  an  ointment  positor  for  introducing  ointments  or  fluids ;  he 
applies  the  iodide  of  mercury  ointment  in  this  way,  and  also  tincture  of 
iodine  on  a  sponge.  lodoform  has  also  been  recently  recommended  by 
Kugelmann,3  the  powder  being  blown,  in  through  a  curved  metal 
catheter.  lodoform  gauze  has  also  been  found  useful  by  Polk4  in 
treating  eiidoinetritis,  especially  the  hsemorrhagic  form ;  the  cervix  is 
dilated  and  the  uterus  washed  out  and  then  packed,  the  gauze  being 
removed  in  twenty-four  hours  and  if  necessary  re-introduced. 

Electricity  has  been  used  in  endometritis  as  in  other  chronic  inflam- 
mations ;  this  will  be  considered  when  the  whole  subject  of  Electricity 
in  Gynecology  is  dealt  with  in  the  Appendix. 

The  importance  of  constitutional  treatment  must  not  be  forgotten. 
The  bowels  should  be  moved  regularly  by  saline  aperients ;  the  aloes 
and  iron  pill  is  also  useful.  The  preparations  of  quinine,  iron,  and 
strychnine,  are  valuable  in  improving  the  tone  of  the  nervous  and 
digestive  systems. 

Cold  baths  and  sea-bathing  aid  greatly  in  strengthening  the  consti- 
tution. The  water  of  certain  mineral  springs,  such  as  Ems  and 
Kreuznach,  seems  to  have  a  special  action  on  the  uterine  as  on  other 
mucous  membranes.  The  regular  diet  and  exercise  required  at  these 
baths  have  also,  no  doubt,  their  beneficial  effect. 

1  Robert  Bell  in  a  paper  read  recently  at  the  British  Gynecological  Society  recommends  it  strongly 
—the  proportions  being  320  grs.  of  iodine  dissolved  in  eight  ounces  of  liquefied  carbolic  acid  :  Brit. 
Gyn.  Trans.,  1888,  p.  189. 

2  Foulerton  lecommends  a  bougie  made  of  fine  wire  twisted  spirally  and  coated  with  nitrate  of 
silver  or  iodoform — Lancet,  Dec.  18SS. 

3  Centralb.  f.  Gyn.,  Bd.  IX.,  S.  648. 

4  Amer.  Jour.  Obs.,  1888,  p.  1052. 


330  AFFECTIONS   OF  UTERUS. 

The   diathesis — strumous,  tubercular,  or   syphilitic — should  not  be 
forgotten.     In  them,  the  treatment  must  from  the  first  be  constitutional. 
Intra-  Intra-uterine  injections.     Applications  to  the  interior  of  the  uterus  are 

Injections.  a^so  made  in  the  form  of  a  fluid  injected  with  a  syringe.  The  nozzle  of 
the  latter  is  shaped  like  a  sound,  so  that  it  may  be  passed  into  the  uterine 
cavity;  the  barrel  is  of  glass,  and  is  graduated  (like  a  hypodermic  syringe) 
so  that  the  quantity  injected  (not  more  than  a  few  minims)  is  exactly 
known.  The  solutions  used  are  carbolic  or  chromic  acid,  tincture  of 
iodine  or  perchloride  of  iron,  nitrite  of  silver,  and  sulphate  of  iron  or 
copper.  The  cervix  must  be  well  dilated,  to  allow  the  fluid  to  escape 
readily  past  the  nozzle  of  the  syringe.  To  facilitate  this  reflux,  syringes 
have  been  devised  with  a  double  canula.  Injection  of  fluid  into  the  non- 
puerperal  uterus  is  not  unattended  with  risk  1  (v.  p.  194),  and  the  fact 
that  we  have  the  equally  effective  and  perfectly  safe  method  of  intra- 
uterine  medication  described  above  renders  it  unnecessary.  As  a  means 
of  treating  endometritis  it  is  condemned  by  the  general  opinion  of  gyne- 
cologists in  this  country  and  America ;  in  France  and  Germany,  however, 
it  is  extensively  practised. 2 

A  new  method  of  dilating  the  uterine  canal  for  therapeutic  purposes  was 
recently  brought  before  the  French  Academy  of  Medicine  by  Vulliet,3 
and  was  referred  to  a  special  committee  who  reported  favourably  on  it. 
It  consists  in  packing  the  uterus  with  tampons,  varying  in  size  from  a 
pea  to  an  almond,  saturated  in  an  ethereal  solution  of  iodoform ;  the 
tampons  are  removed  after  forty-eight  hours  and  a  fresh  series  inserted, 
and  the  operation  is  repeated  eight  or  ten  times  until  the  cavity  has 
become  so  dilated  that  it  can  be  explored  through  its  whole  length  with 
a  speculum,  and  applications  made  more  thoroughly  than  after  any  other 
method  of  dilatation. 

Taylor  of  Birmingham  has  devised  an  "  artificial  amnion  "  (a  finger- 
stall of  pure  rubber,  carried  in  on  a  hollow  sound  and  distended  with  air) 
for  dilating  the  cervix  previous  to  making  applications  to  the  interior  of 
the  uterus,  and  its  use  as  a  preliminary  to  intra-uterine  medication  has 
been  advocated  by  Park.4 

1  A  fatal  case  has  been  recorded  in  the  Lancet,  April  16,  1SS7. 

2  For  further  details  of  this  method  the  student  may  consult  the  following  references :  Klemm — 
Die  Gefahren  der  Uterininjection,"  Leipzig,  1863 ;  Cohnstein—  "  Beitriige  zur  Therapie  der  chronischen 
Aletritis,"  Berlin,  1868;  Lehlond—"  Manuel  de  Gynecologic,"  p.  220,  Paris,  1S7S  ;  and  Hegar  und 
Kaltenbach—"  Operative  Gyniikologie,"  S.  104,  Stuttgart,  1881. 

3  Archiv.  de  Toe.,  Oct.  1886. 

4  Edin.  Med.  Journ.,  Sept.  1887. 


CHAPTER  XXXII. 

METRITIS,  ACUTE  AND  CHRONIC:  SUBIN  VOLUTION. 

LITERATURE. 

Barnes — Diseases  of  Women,  p.  507  :  Lond.  1878.  Sennet,  J.  H. — Practical  Treatise  on 
Inflammation  of  the  Uterus :  London,  1853.  Byford — Medical  and  Surgical  Treat- 
ment of  Women :  Philadelphia,  1881.  Courty — Diseases  of  Women  (Dr.  Agnes 
MacLaren's  Translation  :  Lond.  1882).  De  Sintty — Manuel  de  Gynecologic,  pp.  315 
and  351,  Paris,  1879.  Fritsch — Die  chronische  Metritis  :  Billroth  u.  Luecke's  Hand- 
buch  f.  Frauenkrankheiten,  Stuttgart,  1885.  Gallard — Traitement  de  la  Metrite 
Chronique:  Bull.  gen.  de  therapeut.  etc.,  1879,  T.  XCVII.  4—12,  liv.  Gu6rin— 
Ann.  de  Gyn.,  1878,  Tom.  II.  p.  9.  Klol — Pathologische  Anatomie  der  weiblichen 
Sexualorgane,  S.  124 :  Leipzig,  1878.  Scanzoni — Die  chronische  Metritis :  Wien, 
1863.  Schroedei — Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  84  :  Leipzig, 
1879.  Simpson,  Sir  J.  Y.—  Diseases  of  Women,  p.  585  :  Edin.  1872.  Thomas- 
Diseases  of  Women,  p.  307  :  Philadelphia,  1880.  See  also  Index  of  Recent  Gyne- 
cological Literature  in  the  Appendix. 

DEFINITION. — Inflammation  in  the  muscular  coat  of  the  uterus  leading, 
when  chronic,  to  increased  formation  of  connective  tissue. 

ACUTE  METRITIS. 

PATHOLOGY. 

The  uterus  is  enlarged  and  may  be  of  the  size  of  a  goose's  egg ;  it  is 
thickened,  specially  antero-posteriorly,  and  of  a  doughy  consistence. 
The  peritoneal  surface  is  usually  covered  with  lymph. 

On  section  the  muscular  wall  is  thickened,  but  soft  and  pulpy ;  the 
cut  surface  is  of  a  bright  red  colour,  shows  the  veins  to  be  engorged,  and 
yields  on  compression  a  yellowish-red  exudation.  The  mucous  mem- 
brane is  thickened  and  vascular,  but  the  cavity  of  the  uterus  is  not 
altered  in  size.  Microscopically,  the  muscular  bundles  are  infiltrated 
with  pus  corpuscles. 

ETIOLOGY. 

Acute  metritis  is  produced  by  extension  of  inflammatory  action  from 
the  mucous  or  serous  lining  of  the  uterus  to  the  intervening  muscular 
tissue.  It  occurs  most  commonly  as  part  of  the  general  inflammation 
produced  by  absorption  of  septic  matter  during  the  puerperium.  It  also 
arises  from  exposure  to  cold  at  a  menstrual  period — the  active  congestion 
passing  readily  into  acute  inflammation— from  gonorrhceal  infection  and 
immoderate  sexual  activity. 


332  AFFECTIONS  OF  UTERUS. 

Frequently,  it  is  the  result  of  surgical  interference  : — careless  use  of 
sound,  intra-uterine  injections,  pessaries  and  sponge-tents ;  scraping  the 
-  uterus,  the  removal  of  submucous  fibroids,  operations  on  the  cervix. 

SYMPTOMS. 

There  is  fever  and  general  constitutional  disturbance  varying  with 
the  intensity  of  the  inflammation.  The  onset  may  be  marked  with 
rigors.  There  is  a  sensation  of  fulness,  weight,  and  burning  heat  in  the 
pelvis ;  pain  in  the  hypogastric  and  sacral  regions,  aggravated  on 
movement  of  the  body  or  the  emptying  of  the  bladder  and  rectum ; 
nausea  and  vomiting,  diarrhoea  and  tenesmus  of  rectum  and  bladder. 

Menstruation  is  suppressed  in  those  cases  where  the  metritis  is 
occasioned  by  exposure  to  cold  at  the  menstrual  period.  In  other  cases, 
it  is  diminished  in  amount ;  exceptionally,  there  is  menorrhagia. 

PHYSICAL    SIGNS. 

There  is  tenderness  on  pressure  in  the  hypogastric  region.  On 
vaginal  examination,  the  vaginal  walls  are  hot  and  dry,  the  cervix  is 
swollen  and  movement  of  it  causes  pain.  The  bimanual  examination 
cannot  be  made  on  account  of  the  pain  and  the  resistance  of  the 
abdominal  walls  ;  if  the  patient  be  put  under  chloroform,  the  uterus  will 
be  felt  to  be  enlarged  but  freely  movable  imless  fixed  by  old  adhesions 
(fig.  114).  The  sound  should  not  be  used,  as  it  causes  haemorrhage 
from  the  vascular  mucous  membrane. 

PROGRESS    AND    TERMINATION. 

The  acute  symptoms  do  not  last  usually  more  than  a  week.  The 
fever  and  pain  diminish ;  there  is  less  heat  in  the  pelvis  and  vagina, 
and  leucorrhoeal  discharge  becomes  free.  As  complications,  there  may 
be  catarrh  of  the  bladder,  rectum,  or  vagina. 

The  acute  iisually  passes  into  the  chronic  stage  to  be  immediately 
described ;  though  sometimes,  under  proper  treatment  and  care,  there  is 
resolution  with  absorption  of  the  exudation ;  rarely  does  it  terminate  in 
abscess  formation.  Circumscribed  abscesses  in  the  uterine  walls: — 
recorded  by  Scanzoni,  Reinmann,  Bird,  Ashford,  Schroeder,  Macdonald, 
and  others — are  sometimes  produced  and  burst  into  the  uterus  itself; 
or  adhesions  may  form  and  perforation  take  place  into  the  bladder, 
vagina,  rectum,  and  intestines,  or  even  through  the  abdominal  walls. 

DIAGNOSIS. 

The  diagnosis  that  there  is  acute  metritis  and  nothing  more,  is  a 
refinement  to  which  few  would  lay  claim.  But  if  the  symptoms  and 
physical  signs  are  as  described  above,  if  the  uterus  be  freely  movable 
and  no  deposit  is  felt  in  the  fornices,  we  may  conclude  that  acute 


CHRONIC  METRITIS.  333 

metritis  is  the  prominent  lesion.  The  possibility  of  abscess-formation 
should  be  kept  in  view.  The  practitioner  may  also,  though  very  rarely, 
see  cases  where  there  is  acute  metritis  and  endometritis,  and  nothing 
else.  It  is  wrong  to  say  that  acute  metritis  is  rare.  It  is  often  a 
complication  of  pelvic  peritonitis  and  cellulitis,  with  the  physical  signs 
masked  by  these  latter  diseases. 

PKOGNOSIS. 

The  immediate  result  will  depend  on  the  extent  to  which  the  peri- 
toneum is  involved.  Even  when  the  attack  is  not  severe,  the  liability 
to  pass  into  a  chronic  intractable  condition  makes  us  guarded  in  giving 
an  opinion  as  to  complete  recovery. 

TREATMENT. 

If  the  metritis  is  supposed  to  be   due  to  a  septic  cause,  the   first  Intra- 
measure  indicated  is  the  removal  of  that  cause.       Thus  if  it  come  on  injections, 
during  the  puerperium,  if  the  lochia  are  foetid  and  we  suspect  that  a 
portion  of  the  placenta  has  been  retained,  the  uterine  cavity  should  be 
washed  out  with  an  injection  of  1  to  40  carbolic  or  1  to  4000  corrosive 
sublimate  solution.     Great  care  must  be  taken  not  to  introduce  air  with 
the  injected  fluid. 

In  all  cases  of  metritis,  the  patient  must  be  kept  at  rest.  This 
is  done  by  keeping  her  recumbent.  The  bowels  are  evacuated  by  an 
enema — not  by  purgatives — -followed  by  a  morphia  suppository.  Pain 
is  relieved  by  warm  fomentations,  to  which  turpentine  may  be  added, 
applied  over  the  lower  part  of  the  abdomen ;  but  if  it  be  severe,  the 
patient  should  be  kept  under  the  influence  of  opium  as  already  described 
in  the  treatment  of  pelvic  peritonitis.  If  the  temperature  be  above 
102°,  quinine  should  be  given — 10  grains  every  two  or  three  hours — 
till  it  falls.  The  sulpho-carbolate  of  soda  (15  grains)  is  useful  in  some 
cases. 

CHRONIC  METRITIS. 

SYNONYMS. — Chronic  parenchymatous  inflammation  (Scanzoni),  Sub- 
involution  (Sir  J.  Y.  Simpson),  Diffuse  proliferation  of  connective  tissue 
(Klob),  Infarct  (Kiwisch),  Areolar  hyperplasia  (Thomas). 

There  has  been  great  divergence  of  opinion  among  gynecologists  as  to 
the  term  which  should  be  applied  to  the  changes  occurring  in  chronic 
metritis.  Virchow  describes  the  process  as  a  hyperplasia  of  fibro- 
muscular  tissue,  and  places  chronic  metritis  alongside  of  fibroid  tumours 
of  the  uterus.  Klob  classes  it  among  the  new  formations,  and 
characterises  it  as  "  die  diffuse  Bindegewebswucherung  " — "diffuse  pro- 
liferation of  connective  tissue."  Thomas  calls  it  "Areolar  Hyperplasia," 
and  Noeggerath  has  suggested  the  term  "diffuse  interstitial  metritis." 


334  AFFECTIONS  OF   UTERUS. 

From  a  pathological  point  of  view  the  term  "  nietritis  "  is  incorrect, 
because  there  has  never  been  demonstrated  a  chronic  inflammation 
of  the  muscular  fibre  of  the  uterus.  The  morbid  process  described 
as  chronic  nietritis  consists  in  an  increase  of  connective  tissue  out  of 
proportion  to  that  of  the  muscular  fibre,  which  remains  normal  or  is  but 
slightly  increased  in  quantity.  We  are  not  yet  in  a  position  to  propose 
a  term  resting  on  a  sure  pathological  basis ;  to  do  this  would  require  a 
complete  knowledge  of  the  pathological  changes,  which  has  not  yet  been 
attained.  We  prefer  to  retain  the  term  "  chronic  metritis." 

From  a  clinical  point  of  view,  this  term  is  very  convenient,  including 
a  variety  of  cases  of  different  origin  but  presenting  the  same  clinical 
features  on  examination. 

It  may  be  objected  that  to  apply  the  term  "  chronic  inflammation  " 
to  the  process  is  misleading,  as  it  implies  a  previous  acute  stage  which  is 
rarely  present;  the  process  would  be  more  correctly  described  as  an 
increased  connective-tissue  formation  dependent  on  long-continued 
hypersemia.  But  the  term  chronic  inflammation  is  applied  to  the  pro- 
cess producing  similar  changes  in  other  organs,  as  cirrhosis  of  the  liver ; 
chronic  metritis  produces,  in  fact,  cirrhosis  of  the  uterus. 

Subinvolu-  We  have  brought  "  subinvolution  of  the  uterus  "  under  this  head, 
Uterus.  though  in  other  English  text-books  it  is  treated  as  a  separate  lesion. 
The  term  subinvolution  is  etiological  and  simply  expresses  one  mode,  the 
most  important  one,  in  which  the  condition  to  be  described  is  produced. 
Apart  from  the  history,  it  is  not  possible  to  diagnose  between  a 
subinvoluted  uterus  and  one  enlarged  by  chronic  metritis  alone.  Further, 
the  condition  of  subinvolution  is  maintained  by  the  process  of  chronic 
metritis,  that  is,  by  the  formation  of  connective  tissue  which  takes  the 
place  of  the  muscular  fibre.  Finally,  the  treatment  is  the  same  in  both 
cases. 

PATHOLOGY. 

The  condition  of  the  uterus  depends  on  the  duration  of  the  disease. 
At  an  early  stage  (as  in  cirrhosis  of  the  liver)  the  organ  is  enlarged, 
hyperaemic,  and  soft ;  at  a  later  period  it  is  indurated,  anaemic,  and  hard. 
The  peritoneal  surface  is  of  normal  colour,  or  shows  here  and  there 
patches  of  extravasated  blood.  The  enlargement  is  uniform,  so  that  the 
shape  of  the  uterus  is  not  altered. 

On  section,  the  tissue  is  soft  and  hypersemic  in  the  early  stage ;  firm, 
cartilaginous,  and  of  a  whitish  colour  (from  the  compression  of  the 
capillaries  by  the  cicatricial  tissue)  in  a  later  stage.  The  uterine  walls 
are  increased  in  thickness.  The  uterine  cavity  is  increased  in  size. 
DeSinety.  «  In  the  first  period,"  says  De  Sinety,1  "the  dominant  lesion  is  the 
presence  in  great  number  of  embryonic  elements  throughout  the  whole 

\  Gynecologic,  p.  354. 


CHRONIC  MET1UTIS. 


335 


thickness  of  the  muscular  wall.  These  elements  are  met  Avith  specially 
round  the  blood-vessels  or  form  islands  of  variable  dimensions  which  are 
more  or  less  apart."  The  second  period  is  characterised  by  two 
changes:  (1)  Marked  dilatation  of  the  lymphatic  spaces,  and  (2)  a 
localised  hyperplasia  of  the  connective  tissue  round  the  blood-vessels  (fig. 
199).  The  sclerosis,  for  such  it  may  be  called,  differs  from  a  similar 
change  in  the  kidney  or  liver  in  the  fact  that  the  formation  of 
connective  tissue  is  localised  round  the  blood-vessels.  In  the  case 
described  by  De  Sinety,  he  says  that  it  was  difficult  to  say  whether  the 
muscular  tissue  was  normal  or  diminished  in  quantity. 

Fritsch  x  has  examined  uteri,  extirpated  for  cancer,  which  showed  the  Fritsch. 


tnf,l 


FIG.  199. 

SECTION  OF  THE  UTERINE  TISSUE  IN  A  CASE  OF  CHRONIC  METRITIS  -V*.  c  t  connective  tissue  round  the 
blood-vessels  6  v  ;  I  s  dilated  lymphatic  spaces  ;  mf,  I,  muscular  fibre  cut  longitudinally  ;  mf,  t 
muscular  fibre  cut  transversely  (De  Sinety). 

naked-eye  characters  of  chronic  metritis.  He  notes  the  following  patho- 
logical changes.  (1)  The  disposition  of  the  muscular  fibre  and  connec- 
tive tissue  is  less  regular  than  in  the  normal  uterus,  and  the  latter  is 
increased  in  quantity.  (2)  The  blood-vessels  are  more  numerous  and 
more  tortuous  ;  the  lumen  of  the  vessel  is  often  diminished ;  the  tunica 
media  is  thickened  ;  the  contour  of  the  vessel  is  masked  through  a  con- 
nective tissue  degeneration  of  its  wall.  (3)  The  lymphatic  spaces 
appear  gaping  instead  of  as  narrow  clefts.  (4)  The  peritoneum  is 
thickened. 

1  Luecke  u.  Billroth's  Handbuch  f .  Frauenkrankheiten,  Stuttgart,  1885,  S.  917. 


336  AFFECTIONS   OF  UTERUS. 

Snow  Beck.  Snow  Beck  l  also  describes  the  presence  of  "an  increased  amount  of 
round  and  oval  globules,  with  amorphous  tissue  in  the  uterine  walls." 
The  increase  in  the  size  of  the  uterus  is  due  to  the  presence  of  the  soft 
tissue  rather  than  to  an  increase  in  the  muscular  fibre. 

ETIOLOGY. 

The  causes  of  chronic  metritis  may  be  arranged  under  two  heads  : — 

A.  Causes  which  operate  through  interference  with  the  normal 

involution  of  the  puerperal  uterus ; 

B.  Causes  which  operate  through  the  production  of  repeated  or 

protracted  congestion  of  the  uterus. 

A.  Causes  which  operate  through  interference  with  the  normal  involution 

of  the  uterus. 

(1.)  Retention  of  portions  of  placenta,  membranes,  or  blood- 
clot  in  the  uterus ; 

(2.)  Lacerations  of  the  cervix  uteri ; 

(3.)  Pelvic  inflammations,  occurring  after  labour; 

(4.)  Rising  too  soon  after  delivery  ; 

(5.)  Non-lactation  ; 

(6.)  Repeated  miscarriages. 

Puerperal  In  the  process  of  involution  there  are  two  factors,  the  fatty  degenera- 
lon*  tion  of  the  muscular  fibre  and  the  removal  of  the  products  of  this 
degeneration.  The  condition  of  permanent  enlargement  or  subinvolu- 
tion  is  not  due  to  the  non-degeneration  of  muscular  fibre,  but  to  the 
substitution  of  connective  tissue  for  the  products  of  this  degeneration. 
This  seems  to  be  the  reason  why  the  process  of  chronic  metritis  is  met 
with  more  frequently  in  those  who  have  borne  children.  John  Williams  2 
made  the  interesting  observation  that  involution  was  distinctly  retarded 
by  removal  of  the  ovaries. 

Any  source  of  irritation  in  or  beside  the  uterus  leads  to  chronic 
metritis ;  in  this  way  we  explain  the  effect  of  the  retention  of  portions 
of  placenta  or  membranes.  An  extensive  laceration  of  the  cervix,  Emmet 
says,  favours  subinvolution  for  a  similar  reason.  Continued  cellulitis  or 
peritonitis  acts  in  the  same  way,  or  through  interference  with  the  circula- 
tion. If  the  patient  rise  too  soon,  the  increased  weight  of  the  non- 
involuted  uterus  leads  to  passive  congestion  and  formation  of  connective 
tissue.  Passive  congestion  will,  on  the  other  hand,  be  diminished  by 
whatever  produces  uterine  contractions ;  the  physiological  stimulus  of 
suckling,  excited  reflexly  through  the  mammae,  favours  involution ;  in 
non-lactation  this  stimulus  is  absent.  Abortions  are  an  important  cause  ; 
because  patients  do  not  take  so  much  care  of  themselves  as  after  a  full- 

1  Lond.  Obst.  Trans.,  vol.  xiii.,  p.  239.  2  Lancet,  July  26,  1884. 


CHRONIC  METRITIS.  337 

time  labour,  and  the  stimulus  of  lactation  is  absent.  After  abortion, 
conception  readily  takes  place  before  the  uterus  has  returned  to  its 
normal  size,  and  this  favours  a  recurrence  of  abortion. 

B.   Causes  lohich  operate  through  production  of  repeated  or  protracted 

congestion. 

(1.)  Displacements  of  the  uterus  ; 
(2.)  Pressure  of  tumours  in  or  near  the  uterus  ; 
(3.)  Causes  producing  increased  flow  of  blood  to  the  uterus, 
e.g.  endometritis  or  too  free  use  of  caustics. 

SYMPTOMS. 

In  the  great  proportion  of  cases,  the  patient  dates  her  suffering  from 
a  confinement ;  frequently  there  is  a  history  of  repeated  abortions.  The 
patient  finds,  on  rising  after  the  puerperium,  that  she  does  not  regain 
her  former  strength.  There  is  weakness  in  the  back  amounting  in  more 
severe  cases  to  pain,  a  sensation  of  weight  and  bearing-down  in  the  pelvis 
and  of  want  of  power  in  the  limbs. 

Menstruation  is  irregular  and  often  increased  in  frequency  and  quantity, 
though  this  is  more  characteristic  of  endometritis.  There  is  leucorrhosa 
from  accompanying  endometritis  or  cervical  catarrh. 

The  reproductive  function  is  variously  affected.  Before  the  structure  Effect  on 
of  the  uterus  has  become  permanantly  altered,  pregnancy  followed  byti*£  uc~ 
early  abortion  may  repeatedly  happen.  The  cause  of  the  abortion  is 
probably  the  alteration  which  is  taking  place  in  the  structure  of  the 
mucous  membrane,  rendering  it  unfitted  for  the  development  of  the 
placenta ;  after  an  abortion,  the  conditions  are  peculiarly  favourable 
for  a  second  conception  even  before  the  uterus  has  had  time  to  undergo 
involution;  an  excessive  development  of  connective  tissue  gradually 
renders  the  uterus  incapable  of  involution,  and  thus  the  condition  of 
subinvolution  is  perpetuated.  Should  the  pregnancy  go  on  to  full  time, 
the  presence  of  an  undue  proportion  of  connective  tissue  in  the  uterine 
wall  leads  in  the  third  stage  of  labour  to  atony  of  the  uterus  and 
retention  of  the  placenta ;  see  an  interesting  case  of  this  reported  by 
Kaschkaroff,1  who  gives  the  result  of  his  microscopic  investigation. 
After  the  condition  has  existed  for  some  time,  there  is  sterility.  This  is 
due  not  so  much  to  the  changes  in  the  uterus  itself,  though  the  leucorrhoea 
may  prevent  fertilisation,  but  to  the  ovaritis  or  pelvic  peritonitis  which 
is  usually  superadded ;  ovulation  may  be  prevented  by  change  in  the 
structure  of  the  ovary  or  by  its  being  bound  down  by  adhesions ;  the 
Fallopian  tubes  may  be  obstructed  by  cicatricial  contractions. 

The  general  constitutional  derangements  are  very  important,  and  it 

1  Centralblatt  fur  Gynakologie,  No.  5,  1879. 
Y 


338 


AFFECTIONS   OF  UTERUS. 


Diagnosis 
of  early 
Pregnancj 


is  on  account  of  these  that  the  patients  usually  seek  advice.  Chronic 
metritis  is  the  most  important  of  all  the  diseases  of  women;  the  suffering 
of  the  patient  in  cases  of  displacement  of  the  uterus  is  due  not  so  much 
directly  to  the  displacement  as  to  the  chronic  inflammation  secondary 
to  it. 

PHYSICAL    SIGNS,    DIAGNOSIS. 

The  uterus  is  equally  enlarged  ;  there  is  no  alteration  in  its  form.  The 
character  of  the  enlargement  is  best  understood  by  contrasting  it  with 
that  due  to  pregnancy.  In  the  second  or  third  month  of  pregnancy, 
there  is  antero-posterior  enlargement  of  the  uterus ;  the  vaginal  finger 
comes  on  the  anterior  wall  springing  out  from  the  cervix  ;  the  abdominal 
hand  feels  the  rounding  out  of  the  fundus,  combined  with  a  softness 
which  prevents  us  from  distinctly  denning  its  outline.  In  chronic 
metritis  the  vaginal  finger  does  not  feel  any  bulging  of  the  anterior  wall, 
and  the  abdominal  hand  recognises  the  fundus  to  be  uniformly  thickened  ; 
the  outline  of  the  latter  may  be  felt  with  unusual  distinctness  through 
the  greater  firmness  of  the  uterine  tissue. 

The  enlarged  uterus  may  be  in  its  normal  position,  and  freely  movable 
or  fixed  by  adhesions  ;  it  is  often  retroflexed.  I 

The  sound  passes  more  than  the  2|  inches  ;  it  passes  readily,  and  is 
felt  to  be  freely  movable  in  the  uterine  cavity. 

DIFFERENTIAL   DIAGNOSIS. 

The  conditions  which  are  most  liable  to  be  confounded  with  chronic 
metritis  are  early  pregnancy  and  small  fibroid  tumours. 

In  a  case  of  early  pregnancy,  the  "  having  passed  a  period  "  will  put 
.  us  on  our  guard  ;  some  patients,  however,  menstruate  after  conception. 
Discolouration  of  the  vagina  points  to  pregnancy,  but  is  often  not  marked. 
The  softening  of  the  cervix  is  a  more  reliable  sign,  less  reliable  should 
pregnancy  occur  in  a  uterus  which  has  undergone  changes  of  chronic 
metritis.  Our  only  sure  guide  is  the  bimanual  examination,  which  shows 
us  the  change  in  the  form  and  consistence  described  above.  When  the 
abdominal  muscles  are  resistant,  the  finger  can  recognise  per  rectum  the 
bulging  and  softness  of  the  posterior  uterine  wall.  The  interesting- 
question  suggests  itself  in  this  connection,  how  soon  it  is  possible  to 
recognise  the  changes  in  the  uterus  peculiar  to  pregnancy  ?  How  soon 
can  we  diagnose  pregnancy  ?  Before  auscultation  was  known  the  first 
reliable  signs  were  foetal  movements ;  the  date  at  which  the  mother  first 
recognised  these  varied  indefinitely.  Auscultation  gave  us  an  earlier  and 
more  reliable  indication  in  the  sounds  of  the  foetal  heart ;  these  cannot 
be  heard  before  the  fourth  month.  The  bimanual  examination  enables 
us  to  detect  pregnancy  from  the  eighth  to  the  tenth  week.  We  have 
under  very  favourable  circumstances  diagnosed  it  at  the  fifth  week,  and 
the  subsequent  history  has  confirmed  our  diagnosis. 


CHRONIC  METRITIS.  339 

For  the  differential  diagnosis  of  chronic  metritis  from  small  fibroid 
tumours,  we  refer  the  student  to  the  "  Diagnosis  of  Small  Fibroid 
Tumours"  (Chap.  XXX VI). 

TREATMENT. 

Our  first  object  is  to  diminish  the  passive  congestion  of  the  pelvic 
organs.  The  patient  should  be  instructed  to  lie  down  for  a  few  hours 
every  day.  Sedentary  occupations  or  those  that  require  the  patient  to 
stand  for  a  long  time  in  one  position  should  be  avoided.  While  enjoin- 
ing a  certain  amount  of  rest,  we  must  remember  that  rest  becomes 
injurious  when  it  interferes  with  nutrition.  A  certain  amount  of  exercise, 
especially  in  the  open  air,  should  be  as  emphatically  prescribed  as  a 
certain  amount  of  rest. 

Passive  congestion  is  also  diminished  by  giving  local  support  to  the 
uterus  by  a  Hodge  pessary ;  where  the  vagina  is  roomy,  a  soft  ring 
pessary  sometimes  answers  better. 

The  pelvic  circulation  is  stimulated  by  vaginal  injections  ;  hot  water 
will  generally  be  found  to  be  the  most  valuable ;  cold  water  is  a  more 
effectual  stimulus,  but  few  patients  can  stand  it.  The  vaginal  injection 
should  be  employed  just  before  going  to  bed ;  the  douche  is  preferable 
to  Higginson's  syringe  (v.  page  137).  The  injection  should  be  continued 
from  ten  minutes  to  a  quarter  of  an  hour.  It  is  a  decided  advantage  to 
have  the  douche  given  with  the  patient  in  the  dorsal  posture,  as  Gallard 
recommends.  Occasional  warm  baths  are  useful  in  some  cases ;  when 
the  patient  is  in  the  bath,  the  vaginal  douche  can  be  used  at  the  same 
time  with  greater  freedom  and  effect.  A  cold  hip-bath  every  morning 
is  the  best  stimulus  to  the  circulation.  Medicinal  bathsh&ve  a  peculiarly  Mineral 
beneficial  effect  in  chronic  metritis.  Amongst  those  the  first  place  has^a*^, 
always  been  held  by  Kreuznach,  the  waters  of  which  are  specially  rich  Metritis. 
in  bromides  and  iodides.  The  baths  at  Kissingen  are  rich  in  carbonates, 
and  are  of  a  lower  temperature  than  those  of  Wiesbaden  and  Baden- 
Baden  which  contain  a  smaller  proportion  of  salts. 

Further,  the  drinking  of  medicinal  waters  is  also  beneficial.  The 
mineral  springs  at  Ems  and  Vichy  have,  from  their  action  upon  the 
mucous  membrane,  always  had  a  great  reputation  for  the  treatment  of 
chronic  uterine  inflammation.  Where  there  is  much  catarrh,  they  are 
specially  serviceable.  In  scrofulous  and  chlorotic  individuals,  the  advan- 
tage of  waters  which  are  rich  in  salts  of  iron  is  evident.  Comparatively 
few  of  our  patients,  however,  will  be  able  to  enjoy  the  luxury  of  a  course 
of  treatment  at  one  of  these  watering-places ;  but  much  benefit  will  be 
derived  from  change  of  air  to  the  sea-side,  or  to  the  regular  regime  and 
cheerful  surroundings  of  a  hydropathic. 

Attention  to  the  action  of  the  bowels  is  all  important.  Accumulations 
in  the  rectum  and  sigmoid  flexure  of  the  colon  favour  passive  congestion, 


340  AFFECTIONS  OF  UTERUS. 

and  interfere  with  the  appetite  and  digestion.     The  mineral  waters — 
Friedrichshall,  Carlsbad  and  Hunyadi  Janos — are  the  best  aperients. 

The  Carlsbad  salts  are  specially  useful  in  bilious  patients ;  a  teaspoon- 
ful  should  be  dissolved  in  a  tumberful  of  water  and  drunk  in  repeated 
sips  during  the  morning.  Friedrichshall  and  Hunyadi  Janos  waters  act 
best  mixed  with  an  equal  amount  of  hot  water ;  their  dose  varies  from  a 
wineglassful  to  a  tumblerful.  A  good  substitute  for  these  waters  is  the 
tonic  and  aperient  prescription  given  on  page  206. 

Ergot  (twenty  drops  of  the  liquid  extract  thrice  daily,  increased  to 
thirty  at  the  menstrual  period)  and  the  Hydrastis  Canadensis  (same  dose 
of  its  liquid  extract)  are  very  useful,  especially  when  there  is  menorr- 
hagia. 

The  iodide  and  bromide  of  potassium  may  also  be  given  internally,  as 
recommended  at  page  204. 

Great  care,  and  in  some  cases  complete  rest,  shoiild  be  enjoined  at  the 
menstrual  period.  As  exacerbations  usually  occur  at  these  times,  a  great 
deal  is  done  towards  a  cure  by  prophylactic  measures  in  regard  to  this. 
Blistering  Of  local  treatment  the  most  important  is  counter-irritation  by  occasional 
blistering  or  repeated  application  of  iodine  or  of  croton  oil  to  the  iliac 
regions.  French  gynecologists  recommend  the  application  of  the  blis- 
tering fluid  to  the  cervix ;  we  have  had  no  experience  of  this  method. 
Thomas  speaks  highly  of  it,  and  practises  it  in  the  following  way.  A 
large  cylindrical  speculum  is  passed,  and  the  cervix  cleansed  and  dried 
with  a  pledget  of  cotton.  The  preparation  of  vesicating  collodion,  made 
with  acetic  acid,  is  painted  in  two  or  three  coats  over  the  whole  of  the 
vaginal  portion  ;  after  it  has  dried,  a  stream  of  cold  water  is  applied  to 
wash  off  any  superfluous  collodion.  In  eight  or  twelve  hours  there  is  a 
free  discharge  of  serum.  The  patient  remains  quiet  for  some  days,  and 
uses  occasional  warm-water  injections;  a  pledget  of  cotton  wadding 
soaked  in  glycerine  is  applied  afterwards.  Many  gynecologists  apply 
iodine  to  the  cervix  and  roof  of  the  vagina ;  Scanzoni  recommended  a 
solution  of  4  grs.  of  iodide  of  potassium  in  30  mm.  of  glycerine.  The 
simple  tincture  of  iodine,  or  a  solution  of  equal  parts  of  iodine  and 
glycerine,  may  also  be  applied  in  this  way.  Local  depletion  by  scarifica- 
tion or  leeches,  as  described  under  Endometritis,  is  less  frequently 
employed  than  formerly. 

In  speaking  of  Emmet's  operation,  we  mentioned  that  it  was  sometimes 
followed  by  diminution  in  the  size  of  the  uterus.  Carl  Braun1  has  shown 
that  after  amputation  of  the  cervix  for  hypertrophy  the  uterus  sometimes 
undergoes  changes  which  resemble  those  which  occur  physiologically  in 
the  puerperal  uterus.  Martin  of  Berlin  strongly  recommends  the 
amputation  of  the  posterior  lip ;  in  a  paper  read  before  the  German 
Scientific  Association  at  Cassell,  he  gives  the  results  of  the  operation  in 

1  Zeitechr.  d.  Ges.  d.  Wiener  Aerzte,  1864,  S.  43. 


CHRONIC  METRITIS.  341 

72   cases   in   all   of  which    the    uterus    was    stimulated    to   undergo 
involution. 

Electricity  has  also  been  recommended  by  Apostoli  for  chronic 
rnetritis ;  it  is  more  properly  a  treatment  of  endometritis,  as  it  is  to  its 
cauterising  action  on  the  mucous  membrane  that  beneficial  results  are 
due.  Weir  Mitchell's  method  of  treatment  by  feeding  and  massage  has 
given  good  results  where  the  constitutional  weakness  has  been  the  chief 
source  of  trouble.  Both  of  these  will  be  considered  in  the  Appendix. 


CHAPTER  XXXIII. 

DISPLACEMENTS  OF  THE  UTERUS :  ANTEFLEXION ;  ANTE- 
VERSION  ;  RETROVERSION ;  RETROFLEXION. 

LITERATURE. 

Bandl — Ueber  die  normale  Lage  u.  s.  w.  :  Archiv  f  iir  Gyn. ,  XXII.  408.  Bantock — On  the 
Use  and  Abuse  of  Pessaries  :  London,  1884.  Barnes — Diseases  of  Women,  p.  G79 : 
London,  1878.  Campbell,  H.  F. — Pneumatic  Self-replacement  of  the  Gravid  and 
non-Gravid  Uterus  :  American  Gynecological  Transactions,  Vol.  I.,  1876.  Croom,  J. 
Halliday — The  Management  of  Anterior  and  Posterior  Displacements' of  the  Uterus  : 
Brit.  Med.  Journ.  1888,  I.,  p.  286.  Duncan,  Matthews—  Diseases  of  "Women,  p.  403  : 
London,  1886.  Emmet — Principles  and  Practice  of  Gynaecology,  pp.  278  and  312  : 
Philadelphia,  1884.  A  Study  of  the  Causes  and  Treatment  of  Uterine  Displacement : 
Amer.  Journ.  Obstet.  1887,  p.  1040.  Fritsch—  Die  Lage-veranderungen  der  Gebar- 
mutter  :  Billroth  und  Luecke's  Handbuch,  Stuttgart,  18S5.  Hart — The  Structural 
Anatomy  of  the  Female  Pelvic  Floor  :  Edinburgh,  1881.  Herman — On  the  Relation 
of  Anteflexion  of  the  Uterus  to  Dysmenorrhcea :  Lond.  Obst.  Tr.,  Vol.  XXIII.,  p. 
209.  Pathological  Importance  of  Flexions;  Lancet,  1884,  II.,  pp.  672,  729,  771. 
Hewitt  Graily — The  Mechanical  System  of  Uterine  Pathology :  London,  1878. 
Importance  of  Flexions  and  Displacements:  Lancet,  1884,  I.,  pp.  1020,  1063, 
1110 ;  and  Lancet,  1885,  I.,  pp.  243,  284.  The  Early  History  and  Etiology  of  Flexions 
of  the  Uterus :  Brit.  Med.  Journ.,  1886,  II.,  p.  913.  Mund6—  The  Curability  of 
Uterine  Displacements :  Amer.  Jour,  of  Obst.,  Oct.  1881.  Huge — Congenitale 
Retroflexio:  Zeitschrift  f  iir  Geburtshulfe  und  Gynakologie,  1878,  Band  II.,  S.  24. 
Schroeder— Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  140 :  Leipzig,  1879. 
Schultze,  B.  S. — Ueber  Versionen  u.  Flexionen  u.s.w.  :  Archiv  f.  Gyn.,  Bd.  IV.,  S. 
373.  Zur  Frage  von  der  patholog.  Anteflexion  der  Gebarmutter  :  ibid.,  Bd.  IX.,  S. 
453.  The  Pathology  and  Treatment  of  Displacements  of  the  Uterus — English  Trans- 
lation by  J.  J.  Macan  :  London,  1888.  Simpson,  Sir  J.  Y. — Diseases  of  Women,  pp. 
253,  245,  and  764,  Edin.  1872.  Thomas— Diseases  of  Women,  pp.  363,  408  :  London, 
1880.  Van  De  Warker — The  relation  of  symptoms  to  Versions  and  Flexions  of  the 
Uterus  :  Amer.  Gyn.  Trans.,  1879,  p.  334.  Vedelei — Ueber  Dysmenorrhoe :  Archiv 
fur  Gyn.,  XXI.  211.  Wylie — Prevention  and  Treatment  of  Anteflexion  and  Ante- 
version:  Amer.  Jour.  Obstet.,  1884,  p.  1261;  and  Edin.  Med.  Jour.,  XXX.,  1148. 
See  also  Index  of  Recent  Gynecological  Literature  in  the  Appendix.  Macan 's  trans- 
lation of  Schultze's  work  on  Displacements  has  brought  his  comprehensive  study 
of  the  subject  within  reach  of  English  readers  ;  it  contains  a  good  bibliography  up  to 
1880. 

Prelimi-  As  the  uterus  is  a  movable  organ  within  the  pelvis,  it  is  subject  to 
various  changes  of  position ;  as  it  is  composed  of  muscular  tissue,  it 
is  liable  to  alterations  of  its  normal  curvature.  Both  of  these  changes 
are  described  in  English  text-books  as  "displacements,"  although, 
strictly  speaking,  this  term  should  be  applied  only  to  the  former. 


DISPLACEMENTS   OF  THE   UTERUS.  343 

The  normal  form,  position,  and  relations  of  the  uterus  have  been 
already  described  (see  Chap.  II.). 

The  uterus  is  constantly  exposed  to  forces  producing  a  temporary 
displacement.  In  front  there  is  the  bladder,  the  dilatation  of  which 
displaces  the  uterus  backwards  and  somewhat  upwards  (fig.  42). 
Behind  there  is  the  rectum,  which  normally  should  have  little  influence 
on  the  position  of  the  uterus ;  but,  owing  to  inattention  to  its  regular 
evacuation,  it  is  frequently  over-distended  and  thus  acts  as  a  displacing 
cause  operating  from  above  and  behind.  Above  there  is  the  abdominal 
pressure,  which  is  constantly  acting  on  the  uterus  especially  during 
inspiration.  One  has  only  to  watch  the  movements  of  the  anterior 
vaginal  wall  during  respiration  to  see  that  this  factor  is  always 
operating.  Its  action  is  of  course  increased  by  whatever  increases  the 
intra-abdominal  pressure,  that  is,  by  any  straining  efforts  which  bring  the 
abdominal  muscles  into  play.1  Below  there  is  the  pelvic  floor,  which 
has  a  constant  action  in  supporting  the  uterus  against  the  abdominal 
pressure. 

The  most  important  recent  contribution  on  the  normal  position  of  the  uterus  and  dis- 
placements produced  pathologically  is  from  Ziegenspeck.  He  examined  the  condition 
of  the  pelvis  post-mortem  in  56  cases,  in  35  of  which  he  had  previously  noted  the  condition 
during  life  according  to  Schultze's  method.  After  describing  the  most  important  post- 
mortem changes,  he  mentions  that  he  found  the  uterus  anteflexed  post-mortem  in  24  out 
of  the  56.  His  conclusions  as  to  normal  attachment  of  the  uterus  is  thus  summed  up. 
The  pelvic  floor  almost  altogether  supports  and  holds  the  anteflexed  normally  fixed 
uterus  ;  the  elastic  traction  of  the  vessels  of  the  pelvic  organs  and  of  the  peritoneum  keep 
it  in  this  anteflexed  position.  The  uterus  in  this  position  is  to  a  certain  extent  incorpor- 
ated with  the  pelvic  peritoneum,  its  attachment  to  the  neighbouring  organs  being  only  of 
secondary  importance.  As  to  the  pathological  processes,  he  concludes  that  changes  in 
the  walls  are  only  the  result,  never  the  cause  of  displacement.  The  fixation  of  the  uterus 
was  always  more  marked  in  cases  of  retroflexion  than  in  those  of  pathological  anteflexion. 
Peritonitic  changes  have  little  influence  on  the  position  of  the  uterus,  while  parametric  ones 
are  very  important,  being  present  in  all  cases  of  anterior  and  of  posterior  displacement : 
in  anterior,  affecting  the  utero-sacral  ligaments  ;  in  posterior,  the  cellular  tissue  round 
the  spermatic  vessels  and  beside  the  bladder  and  anterior  fornix  of  the  vagina. 

We  must  distinguish  between  physiological  and  pathological  displace-  Physio- 
ments.     The  former  is  transient,  and  passes  away  when  the  cause  hasp^^.80 
ceased  to  operate ;   the  latter  is  persistent,  and  produces  permanent  logical 
alterations  in  form,  position,  and  stiiicture.     It  is  difficult  to  draw  thements 
line  between  those  two.     The  pathological  condition  is  frequently  due 
to  simple  overstepping   of  the  limits    of  the  physiological.     Thus  the 
carrying  of  the  uterus  backwards  into  a  retroverted  position  by  the 
distention    of  the    bladder   is   physiological,  while    its   remaining  per- 
manently in  that  position  is  pathological. 

1  Tight-lacing  will  intensify  this  action  of  the  abdominal  muscles.  Braxton  Hicks  believes  that 
a  concave  disposition  of  the  abdominal  muscles,  found  in  spare  women,  prevents  the  bladder  from 
expanding  upwards  and  forwards  and  makes  it  either  unduly  antevert  the  uterus  (if  it  be  already 
pathologically  anteverted)  or  retroveit  it : — Lancet,  18S6,  I.,  p.  587. 

-  Ueber  normale  und  pathologische  Anheftungen  der  Gebarmutter  und  ihre  Beziehungen  zu  deren 
wichtigsten  Lageveranderungen :  Archiv  f.  Gyn.,  Bd.  XXXI.  8.  1. 


344  AFFECTIONS  OF  UTERUS. 

It  is  evident  that  the  uterus  can  be  displaced  in  at  least  three  ways  : 
first,  the  different  parts  of  it  may  alter  their  position  relative  to  one 
another ;  second,  it  may  rotate  round  the  transverse  axis ;  third,  the 
organ  may  be  displaced  as  a  whole.  Any  great  rotation  round  the 
vertical  axis  is  prevented  by  the  attachments  of  the  uterus. 

Definitions.  1.  Alteration  in  the  relative  position  of  body  and  cervix  constitutes 
flexion  of  the  uterus,  in  which  there  is  a  change  in  the  curvature  of  the 
long  axis,  i.e.,  in  the  direction  of  the  uterine  canal. 

2.  Rotation  of  the  organ  round  an  imaginary  transverse  axis  con- 
stitutes version  of  the  uterus. 

3.  Displacement    of   the    organ   as   a   whole,    although    frequently 
observed,  has  not  been  described  in  English  works  by  a  precise  term. 
We  might  use  the  term  position  with  the  suitable  prefix.     Thus  when 
the  uterus  lies  "back  as  a  whole  "  in  the  pelvis,  it  might  be  described  as 
"  a  retroposition  "  or  as  "  retroposed  "  (Germ.,  retroponirt). 


FIG.  200. 

DIAGRAMMATIC  SCHEME  OF  FLEXIONS.    The  broken  line  represents  plane  of  brim  ;  the  dark  line,  the 
axis  of  uterus  ;  the  dotted  line  in  o,  its  normal  curvature.     For  letters  see  text. 

The  uterus,  in  its  normal  condition,  is  anteflexed,  anteverted,  ante- 
posed — placed  as  far  forward  as  the  bladder  will  allow. 

Various  deviations  from  the  normal  condition  may  occur. 

(a.)  There  are  three  possible  changes  in  flexion.  To  understand  these, 
suppose  the  direction  of  the  cervix  to  be  fixed.  The  uterine  axis  may  be 
(pathologically)  annexed  (fig.  200  a),  so  that  the  normal  curvature  is 
increased;  this  is  sometimes  associated  with  retroposition.  The  axis 
may  become  straight,  as  occurs  in  so-called  anteversion  (fig.  200  b).  It 
may  also  be  r^roflexed  (fig.  200  c) ;  this  condition  occurs  rarely  by 
itself,  but  associated  with  retroversion  it  is  a  common  displacement. 

(b.)  Version  round  a  transverse  axis  is  either  forwards  or  backwards. 
An  increase  of  the  normal  artfeversion  (fig.  201  a)  is  problematical;  the 
condition  generally  so  described  is  more  often  the  result  of  straightening 


DISPLACEMENTS  OF  THE   UTERUS. 


345 


of  the  uterine  axis  (fig.  200  6).  7?<^roversion  occurs  as  seen  at  fig.  201  b, 
and  is  further  always  present  where  there  is  retroflexion  (fig.  201  c). 

The  body  of  the  uterus  may  also  be  drawn  to  either  side  of  the  pelvis, 
the  cervix  being  directed  to  the  opposite  side.  This  constitutes  lateri- 
version.  Normally,  the  uterus  is  slightly  lateri-verted  to  the  right. 

(c.)  Change  in  position,  or  displacement  of  the  organ  as  a  whole,  is 
upwards,  downwards,  backwards,  or  to  either  side.  Upward  displace- 
ment occurs  in  pregnancy  or  whenever  there  is  a  tumour  present  which 
lifts  the  uterus  out  of  the  pelvis ;  it  is  of  little  pathological  significance. 
Downward  displacement  occurs  in  prolapsus  uteri,  and  will  be  discussed 
under  that  head  (Section  VII.  Affections  of  the  Pelvic  Floor).  A  change 
in  position  bachvards  or  to  either  side  is  produced  by  pressure  or  by 
traction  ;  when  produced  by  cicatricial  contraction,  these  are  the  most 
important  conditions  we  have  to  deal  with. 

We  have  considered  from  a  theoretical  point  of  view  the  variations  in 


FIG.  201. 

DIAGRAMMATIC  SCHEME  OF  VERSIONS. 

flexion  and  version  in  detail,  to  enable  the  student  to  understand  clearly 
what  these  terms  mean.  Too  much  importance  should  not  be  attached 
to  slight  variations ;  the  student  need  only  note  the  following  points. 

1.  The  normal  curvature  may  be  exaggerated — anteflexion. 

2.  The  uterus  may  be  straightened,  the  normal  angle  becoming  less 
pronounced  and  thus  throwing  the  cervix  more  backwards — anteversion. 

3.  The  uterus  may  be  directed  backwards — retroversion. 

4.  It  may  not  only  be  turned  backwards  but  the  normal  angle  may  be 
reversed,    the   fundus   being  bent   backwards    instead   of    forwards — 
retroversion  +  retroflexion. 

5.  The  uterus  may  be  displaced  as  a  whole,  usually  by  cicatricial 
contraction.     This  last  condition  is  the  most  difficult  to  treat. 

The  etiology  of  flexions  and  versions  is  a  subject  of  great  importance.  Etiology. 
In  a  certain  number  of  cases  they  are  congenital,  a  fact  to  be  borne 


346  AFFECTIONS  OF   UTERUS. 

specially  in  mind  with  regard  to  retro  version.  In  many  cases  they  result 
from  inflammatory  conditions, 1  pelvic  peritonitis,  and  especially  cellulitis 
(v.  p.  173).  We  should  therefore  inquire  carefully  into  the  origin  and 
duration  of  the  symptoms,  and  on  making  a  physical  examination  not 
be  content  with  ascertaining  merely  that  there  is  a  displacement  but 
find  out  if  possible  the  cause.  This  will  guide  both  in  prognosis  and 
treatment ;  it  will  indicate  what  cases  we  may  hope  to  cure,  and  what 
cases  we  should  leave  alone.  A  knowledge  of  etiology  enables  us  to 
prevent  the  occurrence  of  displacements,  as,  for  example,  of  retroversion 
in  the  puerperal  condition. 

Frequency.  Of  the  frequency  of  forward  displacements  we  have  no  data,  as  there  is 
no  agreement  as  to  what  is  to  be  considered  a  pathological  degree  of 
ante-flexion  or  -version.  As  to  backward  displacements,  Frankel  found 
them  in  18  p.c.  of  gynecological  cases.2 

Symptoms.  The  symptoms  of  these  displacements  have  given  rise  to  much  discus- 
sion, some  maintaining  that  they  produce  no  symptoms  at  all.  We 
sometimes,  on  examining  a  patient,  find  a  retroflexion  which  has  not 
made  its  presence  felt  by  any  symptoms.  This  is  however  the  excep- 
tion ;  as  a  rule,  backward  displacements  are  followed  by  a  train  of 
symptoms.  This  apparent  contradiction  is  to  be  explained  by  the  fact 
that  flexions  and  versions,  in  themselves,  give  rise  to  no  symptoms 
primarily.  The  symptoms  arise  secondarily :  they  are  due  (1)  to  inter- 
ference with  the  functions  of  menstruation,  conception,  and  pregnancy  ; 
(2)  to  chronic  metritis  and  endometritis  which  is  produced  by  the 
displacement ;  (3)  to  pelvic  cellulitis  and  peritonitis,  which  frequently 
accompany  the  displacement  and  are  often  the  cause  of  it.  Bantock,  in 
his  interesting  monograph  on  the  Use  and  Abuse  of  Pessaries,  gives 
very  fully  the  various  views  held  as  to  the  significance  of  displacements 
as  well  as  the  results  of  his  own  experience. 

Physical  As  regards  the  physical  examination,  it  is  evident  that  the  position 
and  direction  of  the  cervix  is  no  guide  to  the  position  of  the  fundus. 
If  we  had  simply  to  do  with  versions,  we  might  compare  the  uterus  to 
a  lever  of  which  the  body  would  be  the  long  and  the  cervix  the  short 
arm ;  and  the  direction  of  the  short  would  indicate  the  position  of  the 
long  arm.  But  the  possibility  of  flexion  introduces  a  joint  on  the  lever, 
so  that  the  direction  of  the  short  is  no  guide  to  the  direction  of  the  long 
arm.  We  cannot  from  a  simple  vaginal  examination  of  the  cervix  infer 
the  position  of  the  fundus,  which  is  the  point  to  be  ascertained.  A  care- 
ful bimanual  examination,  supplemented  if  necessary  by  the  use  of  the 
sound,  is  essential  for  a  diagnosis. 

1  Ziegenspeck's  researches  confirm  this  from  pathological  anatomy,  and  Emmet  (loc.  cit.)  has 
recently  from  a  clinical  standpoint  emphasised  the  importance  of  pelvic  inflammation  as  causing 
versions  of  the  uterus,  and  would  limit  the  use  of  pessaries  (invaluable  in  suitable  cases)  according]}'. 

2  In  936  of  5180  cases  in  public  and  private  practice  from  1882-85.       He  found  retroflexion 
commoner  than  retroversion,  as  645  to  291.      Ueber  die  Erfolge  der  mechanischen  Behandlung, 
u.  s.  w.  :  Archiv  f.  Gyn.,  Bd.  XXIX.,  S.  316. 


ANTEFLEXION.  347 

As  regards  treatment  the  student  should  recognise  how  many  lesions  Treatment, 
are  present,  and  whether  they  are  causes  or  results ;  a  frequent  chain  is 
that  a  cellulitis  produces  a  displacement  which  is  followed  by  rnetritis, 
endometritis,  and  ovaritis.  In  most  cases  there  is  more  than  one  patho- 
logical condition  present,  and  these  must  be  treated  in  order.  We  first 
check  existing  inflammation  by  hot-water  injections,  blistering,  rest,  and 
the  use  of  the  glycerine  plug. x  Ergot  is  given  when  menstruation  is 
increased.  When  the  absence  of  tenderness  on  examination  has  shown 
that  inflammation  is  checked,  we  then — but  not  till  then — think  of 
treating  the  displacement.  The  time  chosen  should  be  between  two 
menstrual  periods.  In  backward  displacement,  we  bring  the  uterus  to 
its  normal  position  and  retain  it  there.  In  some  cases  of  anteflexion  we 
dilate  or  straighten  the  uterine  canal.  The  after-treatment  requires  more 
attention  than  ike  immediate  correction  of  the  displacement,  and  months 
of  careful  watching  are  necessary.  Thus,  the  keeping  of  the  uterus  in  its 
place  by  a  carefully  adapted  pessary  is  more  important  than  the  replac- 
ment ;  the  keeping  of  the  uterine  canal  open  after  Sims'  operation  is 
more  important  than  the  operation  itself. 

Halliday  Groom  in  a  paper  read  recently  in  the  Obstetric  Section  of 
the  British  Medical  Association  emphasises  the  distinction  between 
displacements  in  virgins  or  nulliparse  and  those  in  parous  women  in 
regard  to  treatment,  the  former  almost  never  calling  for  reposition  and 
the  use  of  pessaries.  The  discussion  on  his  paper  gives  the  most  recent 
expression  of  opinion  as  to  the  importance  and  treatment  of  displace- 
ments. 

ANTEFLEXION. 

PATHOLOGY. 

Anteflexion,  as  has  before  been  stated,  is  merely  an  exaggeration  of  the 
normal  condition.  As  to  its  frequency,  there  is  great  difference  of  opinion. 
The  reason  of  this  diversity  is  that  a  degree  of  flexion  which  would  be 
called  pathological  by  one  observer  would  still  be  called  physiological  by 
another.  The  question  of  symptoms  does  not  help  us  in  deciding  this  ; 
because,  on  the  one  hand,  we  sometimes  find  an  extreme  degree  of  flexion 
although  the  patient  does  not  complain  of  any  special  symptoms ;  on 
the  other  hand,  symptoms  often  described  as  characteristic  are  due  to  a 
different  cause.  It  is  in  fact  worthy  of  consideration  whether  we  should 
not  limit  the  term  anteflexion,  as  descriptive  of  a  special  lesion,  to  cases 
of  pathological  anteflexion  resulting  from  inflammatory  conditions  of  the 
cellular  tissue.  Anteflexion  is  more  frequent  in  nulliparse,  while  retro- 
flexion  is  more  common  in  multiparse. 

The  usual  seat  of  the  flexion  is  at  the  upper  portion  of  the  cervix,  or 

1  Electricity  has  been  used  to  diminish  the  size  of  the  displaced  uterus  and  restore  the  tone  of  its 
supports.— See  Appendix. 


348  AFFECTIONS  OF  UTERUS. 

at  its  junction  with  the  body.  Flexion  of  the  body  itself  is  rare. 
Sometimes  the  cervix  is  bent  sharply  forwards,  so  that  it  lies  in  the  axis 
of  the  vagina  and  forms  a  distinct  right  angle  with  the  body  which  is 
approximately  in  its  normal  position  (see  fig.  202).  In  other  cases,  the 
uterus  is  sharply  curved  on  itself  (see  figs.  38  and  203).  This  last  con- 
dition is  sometimes  mistaken  for  retroversion,  because  the  finger  feels 
through  the  posterior  fornix  the  supra-vaginal  portion  curving  backwards 
and  the  position  of  the  fundus  is  not  ascertained  till  the  bimanual 
examination  is  made.  In  such  cases  the  examination  with  one  finger  in 
the  rectum  is  useful,  as  we  can  thus  get  above  the  point  of  flexion  and 
feel  that  the  fundus  turns  forwards. 


FIG.  202. 

ANTEFLEXION  WITH  STENOSIS  AT  Os  EXTERNUM.      V  vagina,  B  bladder,  p  peritoneum  of  pouch 

of  Douglas  (  Winckel). 

The  vaginal  portion  is  frequently  small  and  the  os  reduced  to  a  pin 
hole  (congenital  cases) ;  sometimes  it  is  high  up  and  difficult  to  reach, 
being  drawn  upwards  and  backwards  by  cicatricial  bands.  As  regards 
the  microscopic  changes  in  the  tissue,  we  are  still  in  want  of  information. 
Virchow  found  no  fatty  degeneration  of  muscular  fibre  at  the  angle  of 
flexion ;  the  tissue  was  anaemic  at  this  point  but  congested  elsewhere. 
According  to  Rokitansky,  the  connective  tissue  framework  of  the  uterus 
is  thinnest  at  the  os  internum ;  hence  the  liability  to  flexion  at  this 
point. 


ANTEFLEXION. 


349 


ETIOLOGY. 


Etiologically  we  distinguish  two  kinds  of  anteflexion,  the  congenital 
and  the  acquired. 

In  cases  in  which  the  anteflexion  is  congenital,  the  whole  uterus  is  Congenital 
imperfectly  developed,  the  cervix  is  small   and  the  pin-hole  os  looks 


FIG.  203. 

DIAGRAM  TO  SHOW  ANTEFLEXIOS  PRODUCED  BY  CICATRISATION  OF  UTERO-SACRAL  LIGAMENTS.  The 
arrows  indicate  the  direction  of  the  forces  modifying  the  position  and  curvature  of  the  uterus ; 
the  dotted  line  the  outline  of  the  ilium.  (Schultze) 

downwards  and  forwards.  Fritsch  gives  an  ingenious  explanation  of 
how  the  flexion  is  produced  in  such  cases.  The  uterus  of  the  new-born 
child  has  thin  walls  and  is  flexible  :  the  intra-abdominal  pressure  acts  on 


350 


AFFECTIONS  OF  UTERUS. 


Acquired 
Ante- 
flexion. 


Hewitt's 
Views. 


the  posterior  surface  of  the  fundus  and  produces  anteflexion ;  this  action 
is  counteracted  by  the  bladder  on  which  the  uterus  is,  as  it  were, 
moulded ;  when  the  uterus  remains  small  and  thin-walled,  it  does  not 
offer  such  a  large  surface  to  the  bladder  so  as  to  be  raised  by  it  and  have 
its  flexion  undone.  Accordingly,  a  pathological  degree  of  anteflexion  is 
produced.  The  same  writer  would  also  refer  some  cases  to  congenital 
shortening  of  the  utero-sacral  ligaments. 

As  regards  acquired  anteflexion,  it  is  undoubtedly  often  the  result  of 
inflammatory  changes  behind  the  uterus.  In  many  cases  of  anteflexion, 
we  observe  that  the  cervix  is  higher  than  its  normal  position  and  far 
back  in  the  pelvis ;  and  that  the  attempt  to  bring  it  to  its  normal 
position  produces  pain.  The  cause  of  this  condition  was  first  brought 
into  notice  by  Schultze,1  who  ascribes  it  to  a  cellulitis  in  the  utero- 
sacral  ligaments  ;  this  produces  cicatricial  contraction  so  that  the  cervix 
is  drawn  upwards  and  backwards,  and  the  fundus  thrown  more  forwards. 
Bandl  thinks  the  first  step  in  the  process  is  a  cervical  catarrh ;  and  that 
the  inflammation  spreads  from  the  mucous  membrane  to  the  tissue  of 
the  cervix  itself,  making  it  more  rigid,  and  thence  to  the  cellular  tissue 
round  the  cervix.  Schroeder,  however,  holds  that  the  retraction  of  the 
cervix  is  produced  by  adhesions  resulting  from  peritonitis.  We  draw 
attention  specially  to  this  cause  of  anteflexion,  because  it  can  be  dis- 
tinctly made  out  by  careful  examination.  When  it  has  been  made  out 
it  is  a  contra-indication  to  hasty  operative  interference,  and  the  prog- 
nosis as  to  cure  is  unfavourable. 

Graily  Hewitt  refers  this,  as  all  other  flexions,  to  softness  of  the 
uterine  tissue  and  thinness  of  wall,  producing  undue  flexibility. 

It  is  alleged  that  a  fibroma,  or  other  tumour  increasing  the  weight  of 
the  fundus,  will  favour  anteflexion  if  the  fundus  be  directed  forwards. 
In  the  commencing  enlargement  of  pregnancy,  the  fundus  droops  more 
forwards  or  is  at  least  more  distinctly  felt  through  the  anterior  fornix. 

Unequal  growth  of  the  uterine  walls  has  been  given  as  the  cause  of 
congenital  flexions,  and  unequal  involution  of  the  walls  as  the  cause  of 
flexions  acquired  during  the  puerperium.  This  is  merely  an  explana- 
tion of  how  it  is  produced  ;  the  cause  of  this  unequal  growth  requires,  in 
turn,  an  explanation. 

SYMPTOMS. 

The  most  important  symptoms  of  pathological  anteflexion  are — 

Dysmenorrhcea, 

Sterility. 
In  addition  to  these  there  are  sometimes  present — 

Leucorrhosa, 

Menorrhagia. 

1  Loc.  cit.  8.  414. 


ANTEFLEXION.  351 

It  will  be  noted  that  these  are  the  symptoms  of  pelvic  and  uterine 
inflammation  and  are  not  pathognomic. 

In  many  cases  we  find  a  well-marked  anteflexion  giving  rise  to  no 
symptoms  which  patients  complain  of,  as  they  are  not  accustomed  to 
speak  of  sterility  as  a  symptom. 

Dysmenorrhoea.  By  this  we  understand  that  menstruation  is  accom- 
panied with  pain.  The  form  of  dysmenorrhoea  present  in  anteflexion 
has  been  called  "uterine,"  in  contradistinction  to  "ovarian"  (see 
Dysmenorrhoea,  Section  VIII.)  By  "  uterine  dysmenorrhosa,"  is  meant 
that  the  pain  is  not  marked  until  the  menstrual  flow  has  appeared  and 
that  it  continues  as  long  as  the  discharge  continues.  The  pain  is  felt 
in  the  small  of  the  back  and  sometimes  in  the  pelvis  generally,  but  is 
not  localised  in  one  ovarian  region. 

Two  different  explanations  of  this  pain  have  been  given.  For  con- 
venience we  describe  these  as  the  obstruction  and  the  congestion 
theories. 

1.  The    obstruction   or   mechanical    theory.      According   to   this,    the  Mechanical 
flexion  of  the  uterus  produces  a  narrowing  of  the  uterine  canal  at  the  Dysnieii^ 
point  of  flexion. x     Hence,  when  the  menstrual  decidua  and  blood  areorrhcea. 
shed,  they   find  an  obstacle   to  their  free  exit.      There  is  consequent 
retention   and    coagulation,  and  the    coagula  stimulate  the   uterus  to 
muscular   contractions    to   effect    their    expulsion.       The    mechanical 
resistance  to  the  outflow  of  blood  and  the  uterine  contractions  excited  to 
overcome  this,  are  the  cause  of  the  pain.     The  condition  is  like  that 

in  stricture  of  the  male  urethra.  The  blood,  like  the  urine,  collects 
but  cannot  be  passed  without  pain ;  there  is  dilatation  with  sometimes 
secondary  hypertrophy  of  the  uterus  in  the  former  case,  as  of  the 
bladder  in  the  latter.  It  may  fairly  be  objected  to  this  mechanical 
explanation  that  the  discharge  is  not  always  clotted,  that  in  some  cases 
it  is  very  small  in  quantity,  that  it  is  doubtful  whether  the  blood  coagu- 
lates in  the  uterus,  and  that  in  many  cases  the  pains  complained  of  have 
not  the  distinctive  character  of  labour  pains.  What  has  been  already 
said  with  regard  to  Dysmenorrhcaa  ascribed  to  Stenosis  of  the  Os 
externum  (v.  p.  267)  holds  good  also  here. 

2.  The  congestion  theory  is  clearly  stated  and  advocated  by  Fritsch. 2  Congestion 
According  to  this  gynecologist,  the  dysmenorrhoea  is  not  due  directly  toTteorj' 
the  bend  on  the  canal.     The  pain  arises  from  the  resistance  which  the 
muscular  tissue  of  the  uterus  offers  to  the  hypersemia.     In  normal  cases, 

this  tissue  yields  to  the  distending  vessels  ;  but  when  the  uterus  is  small 
or  bent  on  itself,  there  is  an  obstruction  offered  to  the  flow  of  blood. 
The  mucous  membrane  cannot  swell  up  as  it  does  normally.  Thus  there 

1  It  is  doubtful  whether  this  occurs.     Graily  Hewitt  (Brit.  Med.  Journ.  1888,  I.,  4ol)  figures  a 
specimen  where  the  lumen  of  the  tube  is  flattened  out  laterally  at  the  angle  of  flexion. 

2  Loo.  cit.  S.  35. 


352 


AFFECTIONS  OF  UTERUS. 


Ante- 
flexion  and 
Dysmen- 
orrhcea. 


Sterility. 


is  undue  vascular  tension  and  compression  of  the  nerve  endings  in  the 
uterus.     This  last  causes  the  pain. 

Whether  this  explanation  harmonises  better  with  the  facts  it  is 
difficult  to  say ;  but  we  should  suggest  a  modification  of  Fritsch's  view. 
The  flushing  of  any  diseased  tissue  with  blood  causes  an  aggravation  of 
pain,  which  is  increased  if  the  tissue  be  of  a  dense  structure.  The 
intense  pain  in  periostitis  as  the  affected  limb  becomes  warm  in  bed, 
is  thus  accounted  for.  Now  the  tissues  of  the  uterus  are  frequently 
in  a  state  of  chronic  inflammation,  and  there  is  sometimes  increase  of 
connective  tissue  making  it  of  less  yielding  structure ;  this  occurs  in 
retroflexion  complicated  with  subinvolution.  The  monthly  flushing  of 
the  pelvis  with  blood  would,  under  these  circumstances,  be  accompanied 
with  pain.  We  must  also  remember  that  cellulitis  and  peritonitis  are 
often  present  with  anteflexion ;  and  increase  of  pelvic  congestion  will, 
of  course,  produce  increase  of  pain. 

Herman  and  Vedeler  have  shown  that  the  connection  between  Ante- 
flexion  and  Dysmenorrhcea  has  been  over-estimated.  In  his  very 
interesting  paper  on  the  cause  of  Dysmenorrhoea,  Vedeler  reports  on  a 
large  number  of  cases  (observed  by  himself)  of  patients  with  and  with- 
out Dysmenorrhoea.  To  ascertain  the  relation  of  this  symptom  to 
anteflexion  we  extract  from  his  tables  all  the  cases  of  nulliparse  with 
uterus  to  the  front :  we  take  nulliparous  cases  only,  because  parity  in 
itself  affects  anteflexion ;  and  consider  cases  with  uteri  to  the  front,  as 
we  are  dealing  with  ante-flexion  only.  We  find  that  37 '3  p.c.  (25  out 
of  67)  of  patients  with  Dysmenorrhoea  had  a  well-marked  anteflexion,  and 
that  33*3  p.c.  (46  out  of  138)  of  patients  without  Dysmenorrhoea  also 
had  well-marked  anteflexion.  The  first  fact  by  itself  would  lead  us  to 
suppose  that  anteflexion  was  frequently  a  cause  of  Dysmenorrhoea,  but, 
taking  it  along  with  the  second,  all  that  we  can  say  is  that  anteflexion 
is  rather  more  common  in  cases  of  Dysmenorrhoea  than  otherwise. 
Unfortunately,  Vedeler  does  not  distinguish  between  anteflexion  per  se 
and  that  secondary  to  inflammatory  changes  behind  the  uterus. 

Sterility  is  frequently  associated  with  anteflexion  ;  the  patient  is  not 
so  likely  to  refer  to  it,  as  the  dysmenorrhoea  is  the  more  pressing  symptom 
and  that  for  which  she  seeks  advice.  This  symptom  has  been  referred 
to  the  obstruction  in  the  uterine  canal ;  as  the  menstrual  blood  is  pre- 
vented from  passing  downwards,  so  the  spermatozoa  are  prevented  from 
passing  upwards  (v.  also  p.  268).  But  it  is  evident  that  this  mechanical 
explanation  is  insufficient,  because  no  mere  contraction  could  prevent 
the  passage  of  microscopic  spermatozoa;  without  doubt  sterility  is 
frequently  the  result  of  the  binding  down  of  the  ovaries  or  the  Fallopian 
tubes  by  concomitant  inflammation.  However  we  explain  it,  the 
clinical  fact  remains  that  by  passing  the  sound  or  dividing  the  cervix 
we  place  the  patient  under  more  favourable  conditions  for  conception. 


ANTEFLEXION.  353 

Dyspareunia — pain  on  sexual  intercourse — is  occasionally  an  important 
symptom,  though  naturally  the  patient  does  not  refer  to  it.  In  such 
cases  we  generally  find  that  there  is  inflammatory  action  behind  the 
cervix. 

Leucorrhoea  is  generally  present,  more  especially  if  the  uterus  be 
enlarged.  It  is  not  so  important  a  symptom  as  it  is  in  retroflexion. 

Menorrhagia  is  sometimes  present,  when  there  is  uterine  enlargement 
or  endometritis  as  the  result  of  anteflexion. 

PHYSICAL    DIAGNOSIS. 

• 

On  making  the  vaginal  examination  the  cervix  is  felt  to  be  high  up, 
and  lies  in  the  axis  of  the  vagina  with  the  os  looking  downwards  and 
forwards.  It  may  be  small  and  conical  with  a  pin-hole  os  (congenital,  v. 
fig.  155);  or  the  anterior  lip  may  be  elongated,  the  end  of  the  cervix 
being  at  the  same  time  somewhat  flattened  against  the  posterior  vaginal 
wall.  The  body  of  the  uterus  is  felt  in  the  anterior  fornix  continuous 
with  the  cervix,  with  which  it  forms  a  distinct  angle  in  which  the  tip  of 
the  finger  may  be  placed.  If  the  flexion  be  high  up  or  the  uterus  drawn 
upwards,  the  body  may  not  be  felt  on  simple  vaginal  examination.  Even 
if  it  be  felt,  we  cannot  be  certain  that  it  is  the  body  of  the  uterus  till  the 
Bimanual  is  made  as  follows.  Endeavour  to  get  the  body  felt  in  the 
anterior  fornix  fairly  between  the  hands ;  by  examining  all  round,  make 
sure  that  what  is  grasped  is  the  body  of  the  uterus.  Now  place  the 
index  finger  under  the  fundus  in  front  of  the  angle  and  the  middle 
finger  against  the  cervix  ;  and,  making  pressure  with  the  external  hand, 
ascertain  to  what  extent  the  flexion  yields.  Examine  carefully  the 
posterior  fornix  to  see  if  there  are  any  bands  drawing  the  cervix  back- 
Avards,  try  whether  bringing  the  cervix  forcibly  forwards  causes  pain, 
which  would  indicate  an  inflammatory  condition  in  the  utero-sacral 
ligaments  or  the  presence  of  adhesions  in  the  pouch  of  Douglas.  We 
can  ascertain  this  even  better  by  passing  the  middle  finger  into  the 
rectum,  and  at  the  same  time  making  the  bimanual  examination  with 
the  index  finger  in  the  vagina.  The  finger  in  the  rectum  feels  a 
pouch  in  the  anterior  rectal  wall  bounded  by  a  tense  band  on  each  side 
(utero-sacral  ligaments),  or  one  or  more  cord-like  adhesions  (the  result 
of  former  peritonitis),  or  a  general  resistance  to  pressure  which  produces 
pain.  Any  of  these  conditions  indicates  that  the  cause  has  been  inflam- 
mation which  has  produced  cicatrisation  behind  the  cervix. 

Though  the  bimauual  examination  is  in  many  cases  sufficient,  it  may 
be  supplemented  by  the  use  of  the  sound.  This  is  necessary  for  differ- 
ential diagnosis,  and  its  frequent  introduction  constitutes  one  form  of 
treatment.  Curve  the  sound  to  correspond  to  the  angle  of  flexion.  It 
will  be  found  to  pass  with  comparative  ease  for  about  an  inch  or  an 
inch  and  a  half,  and  then  it  is  stopped  by  the  angle  of  flexion.  To  get 
z 


354 


AFFECTIONS   OF   UTERUS. 


Differ- 
ential 
Diagnosis 
of  Ante- 
flexion. 


it  past  this,  press  up  the  fundus  through  the  anterior  fornix  Avith  the 
finger  in  the  vagina  or  draw  down  the  uterus  with  the  volsella.  The 
sound  shows  that  the  length  of  the  uterine  cavity  is  sometimes  diminished 
(congenitally  small  uterus),  sometimes  increased  (the  result  of  the 
obstruction  to  the  out-flow  of  menstrual  blood).  It  may  further  show 
tenderness  in  the  uterine  cavity  (endometritis).  The  use  of  the  sound 
is  undesirable  where  there  is  inflammation  behind  the  uterus ;  and,  when 
the  Bimanual  places  the  diagnosis  beyond  doubt,  it  is  unnecessary  except 
for  treatment. 

• 

DIFFERENTIAL    DIAGNOSIS. 

The  only  conditions  which,  after  this  careful  examination,  might  yet  be 
mistaken  for  an  anteflexion  are — 

Myoma  in  the  anterior  uterine  wall, 

Cellulitis  between  the  cervix  and  the  bladder — a  very  rare  condition. 


FIG.  204. 

SOUND  PASSED  TO  SHOW  THAT  A  MYOMA  or  THE  ANTERIOR  WALL  is  NOT  AN  ANTEFLEXION  (Leblond), 


Diagnosis 

from 

Myoma, 


From 

Cellulitis. 


A  myoma  is  easily  diagnosed  by  the  sound.  As  in  anteflexion,  a  body 
is  felt  in  the  anterior  fornix ;  and  we  must  ascertain  whether  this  body 
is  the  fundus  uteri.  When  the  sound  is  passed  into  the  uterus  (fig. 
204)  in  a  case  of  myoma,  a  finger  in  the  anterior  fornix  does  not  feel  the 
sound  or  feels  that  a  body  lies  between  it  and  the  instrument.  Now 
make  the  bimanual  examination  with  the  sound  in  the  uterus ;  the 
position  of  the  fundus  is  indicated  by  the  external  hand's  feeling  the 
point  of  the  sound. 

The  diagnosis  from  cellulitis  is  less  easy,  because  through  the  tender- 
ness it  is  difficult  to  ascertain  whether  the  body  felt  in  the  anterior  fornix 
is  the  fundus  uteri  or  a  cellulitic  deposit.  A  careful  bimanual  examina- 


ANTEFLEXION. 


355 


tion  will,  if  it  be  a  cellulitic  deposit,  show  that  the  fundus  uteri  is  lying 
in  some  other  position.  When  active  inflammation  is  present,  the  use  of 
the  sound  is  contra-indicated. 

PROGNOSIS. 

The  prognosis  should  always  be  guarded  in  respect  of  the  disappear- 
ance of  symptoms.  The  unfavourable  cases  are  those  in  nulliparse,  due 
to  utero-sacral  cellulitis. 

TREATMENT. 

Pelvic  inflammation,  if  present,  must  first  be  treated.  Where  the 
uterus  is  displaced  by  cicatricial  bands,  the  stretching  of  these  by 
massage  has  been  suggested  and  is  worthy  of  trial. 

In  cases  uncomplicated  by  pelvic  inflammation  and  where  there  is  Treatment 

by  Sound. 


FIG.  205. 
GREENHALGH'S  INTRA-UTERINE  STEM. 

dysmenorrhoea,  the  occasional  introduction  of  the  sound,  say  twice -a-week 
between  the  menstrual  periods,  is  sometimes  followed  by  distinct  relief 
of  the  symptoms.  It  has  the  advantage  of  being  easily  done,  is  seldom 
followed  by  injurious  effects  if  done  with  ordinary  care,  and  should 
always  be  tried  in  the  first  instance.  The  passage  of  bougies  is  also 
useful;  it  has  already  been  referred  to  under  the  treatment  of  rigid 
cervix  (v.  p.  266). 

Intra-uterine  stem  pessaries  have  also  been  recommended.     We  have  Treatment 
already  described  the  galvanic  stem  and  its  mode  of  introduction  at  y 
p.  277.     Fig.  205  shows  Greenhalgh's  gutta-percha  stem  which  is  carried 
in  on  the  ordinary  uterine  sound.     Thomas1  has  recently  recommended 

1  The  Etiology,  Pathology,  and  Treatment  of  Anteflexions  of  the  Uterus  :  Am.  Journ.  of  Obstet., 
1888,  p.  1042. 


356  AFFECTIONS   OF  UTERUS. 

glass   steins  supported  in  a  Hodge   pessary  with   a   cup.      All   stem 
pessaries  must  be  used  with  great  caution. 

Treatment  Division  of  the  cervix  may  also  be  performed.  It  is  only  indicated 
of  Cervix,  where  there  is  much  cervical  catarrh.  The  best  mode  of  performing  it 
is  by  the  bilateral  operation  of  Sir  J.  Y.  Simpson,  described  at  p.  271. 
Marion  Sims  introduced  the  antero-posterior  division  represented  in  fig. 
206.  The  posterior  lip  of  the  cervix  is  divided  to  the  fornix  and  the  pro- 
jecting angle  of  the  anterior  wall  incised  by  a  tenotomy  knife  passed 
into  the  cervical  canal.  This  operation  was  based  on  the  mechanical 
theory  of  Dysmenorrhcea  (v.  pp.  267,  351),  and  stands  or  falls  with  that 
theory  ;  its  object  is  to  make  a  new  straight  canal. 

The  treatment  of  anteflexion  by  specially  adapted  vaginal  pessaries  is 
recommended  by  Thomas  and  others,  but  it  is  not  a  scientific  one.  It  is 
wrong  in  principle,  because  the  fundus  uteri  cannot  be  propped  up  by  an 
arm  of  the  pessary  projecting  through  the  anterior  fornix  so  as  to  diminish 


FIG.  206. 

SIMS'  DIVISION  OF  CERVIX  ;  a  incision  in  posterior  lip,  b  incision  at  knee  of  flexion  (Marion  Sims). 

the  angle  of  flexion.  In  some  cases  where  the  uterus  is  large  and  heavy 
we  find  that  benefit  is  derived  from  supporting  the  uterus  as  a  whole. 
But  this  is  best  effected  by  an  ordinary  vaginal  pessary  (Hodge  or  Albert 
Smith),  and  is  not  a  mode  of  treatment  of  anteflexion  specially.  We 
shall  refer  to  this  again  under  the  treatment  of  anteversion. 

ANTEVEBSION. 
PATHOLOGY   AND   ETIOLOGY. 

The  pathological  change  consists  in  a  straightening  of  the  uterine  axis, 
so  that  the  normal  angle  of  forward  curvature  is  diminished  and  the 
cervix  passes  more  directly  backwards.  The  uterus  is  usually  enlarged 
and  its  texture  is  firmer.  In  this  condition  it  is  movable  or  fixed.  If 
the  former,  its  position  varies  with  the  distention  of  the  bladder  ;  if  the 


ANTEVERSION.  357 

latter,  the  fixed  uterus  will  press  more  or  less  on  the  bladder  as  it  dis- 
tends and  thus  produce  one  of  the  symptoms  of  anteversion. 

According  to  Fritsch,  the  fixation  of  the  uterus  is  never  to  the  pubes  ; 
this  is  because  the  bladder,  lying  between  the  fundus  and  the  symphysis, 
prevents  adhesions  from  forming.  On  post-mortem  examination  of  a  case 
in  which  he  had  diagnosed  anteversion  with  fixation,  he  found  that  the 
fundus  was  bound  down  at  its  left  angle. 

ETIOLOGY. 

As  anteversion  is  the  form  and  position  taken  up  by  the  uterus  when  it  Signifl- 
is  enlarged  through  chronic  metritis,  the  causes  which  produce  antever-6^^.' 
sion  are  those  which  produce  chronic  metritis — subinvolution,  laceration  version, 
of  the   cervix,  and   other   causes  of  pelvic    inflammation  (y.   Chronic 
Metritis). 

This  position  also  occurs  physiologically  in  early  pregnancy ;  probably 
because  the  increased  weight  of  the  uterus  causes  it  to  fall  more  forwards. 

SYMPTOMS. 

There  are  no  symptoms  characteristic  of  anteversion  per  se  ;  but  we 
generally  find  present,  in  the  first  place,  the  local  symptoms  of  chronic 
uterine  and  pelvic  inflammation. 

Thomas  draws  attention  specially  to  loss  of  power  in  walking — when 
the  version  was  treated,  power  was  restored ;  this  was  probably  a  reflex 
phenomenon.  Sometimes  there  are  symptoms  due  to  interference  with 
the  functions  of  the  bladder  and  the  rectum.  Pressure  of  the  fundus 
(when  the  uterus  is  fixed)  on  the  bladder  produces  frequent  calls  to 
micturition ;  pressure  of  the  cervix  on  the  posterior  wall  of  the  vagina 
is  said  to  produce  erosion  and  catarrh,  and  on  the  anterior  wall  of  the 
rectum  to  cause  painful  defecation.  These  last  two  are  very  doubtful. 

Further,  we  may  have  the  train  of  general  symptoms  which  follow 
any  long-standing  disturbance  of  the  reproductive  system,  viz.,  derange- 
ments of  the  digestive  and  nervous  systems.  Schroeder  draws  atten- 
tion to  the  fact  that  discomfort  is  often  produced  when  the  uterus  is 
enlarged  but  freely  movable,  and  that  this  is  due  to  the  heavy  organ's 
becoming  displaced  on  the  movements  of  the  patient ;  further,  that  it  is 
relieved  if  the  uterus  is  fixed  by  a  vaginal  ring  pessary. 

DIAGNOSIS. 

There  is  usually  110  difficulty  in  diagnosis.  The  finger  in  the  vagina 
feels  the  cervix  passing  directly  backwards,  the  os  looking  towards  the 
hollow  of  the  sacrum.  The  body  of  the  uterus  is  distinctly  felt  through 
the  anterior  fornix ;  and  on  tracing  it  back  to  its  junction  with  the 
cervix,  we  do  not  feel  the  normal  forward  curvature.  The  whole  organ 
is  usually  enlarged  and  firm  in  texture.  From  the  distinctness  with 


358  AFFECTIONS  OF  UTERUS. 

which  the  uterus  is  felt  when  the  bladder  is  empty,  we  might  infer 
that  only  the  anterior  vaginal  wall  lay  between  it  and  the  finger.     But, 
if  we  make  the  examination  when  the  bladder  is  partially  distended  or 
Bladder      pass  the  sound  into  the  empty  bladder,  we  find  that  that  organ  passes 
i/ Ante™8  backwards  almost  as  far  as  the   cervix  uteri.      Perhaps  the  bladder 
version.       symptoms  (which  are   present   in   marked   cases)  might   be    explained 
through  the  traction  thus  made  on  its  walls  and  its  abnormal  posi- 
tion, these  interfering  with  its  dilatation. 

The  bimanual  examination  shows  that  the  body  felt  in  the  anterior 
fornix  is  the  fundus  uteri.  The  student  should  not  however  be  content 
with  this  knowledge,  but  should  examine  carefully  the  size  and  mobility 
of  the  uterus;  and,  when  it  is  fixed,  should  ascertain  the  cause  of 
this. 

The  introduction  of  the  sound  is  difficult  on  account  of  the  high 


FIG.  207. 

GRAILY  HEWITT'S  CRADLE  PESSARY,    a  is  in  posterior  fornix  ;  6  at  vaginal  orifice  ;  c  in  anterior 

fornix  (Barnes}. 

position  of  the  os,  and  its  use  is  unnecessary  except  in  cases  of  doubt  as 
to  whether  the  body  felt  anteriorly  is  the  fundus  uteri. 

The  only  case  in  which  there  is  difficulty  in  differential  diagnosis  is 
when  there  has  been  inflammatory  deposit  in  front  of  and  around  the 
cervix,  simulating  the  anteverted  fundus.  In  these  cases  the  combined 
examination  is  difficult  from  existing  inflammation.  The  examination 
with  one  finger  in  the  rectum  enables  us,  in  such  cases,  to  ascertain  that 
the  fundus  uteri  is  at  least  not  lying  to  the  back. 

TREATMENT. 

From  what  we  have  said  in  regard  to  the  symptoms,  it  follows  that 
the  treatment,  in  the  first  instance,  is  that  of  endometritis,  metritis, 
cellulitis,  or  peritonitis,  according  to  the  condition  which  is  present. 


ANTEVERSION.  359 

As  regards  the  supporting  of  the  uterus,  great  benefit  may  be  derived 
from  the  glycerine  plug,  which  in  this  case  should  be  well  packed  into 
the  posterior  fornix.  The  simple  vaginal  pessary  (Hodge,  Albert 
Smith,  ring)  is  useful  in  supporting  the  uterus  as  a  whole,  and  in  fixing 
the  cervix. 

As  already  said  under  anteflexion,  the  fundus  cannot  be  immediately  Ante- 
supported  through  the  anterior  vaginal  wall.     Various  forms  of  pessary  p^aries 
have  been  devised,  but   none   can   be   recommended.      There   is   the 
"cradle   pessary"   of    Graily   Hewitt    (fig.    207),   made   of  vulcanite. Hewitt's. 
Munde   strongly   recommends    an    anteversion    pessary   by   Gehrung.  Gehrung's. 
Thomas  has  devised  several  forms  of  anteversion  pessary,  of  which  one  Thomas', 
is  represented  at  fig.  208.     It  is  simply  a  Hodge  pessary,  with  a  pro- 
jecting bar  which  passes  into  the  anterior  fornix  and  tilts  the  cervix 
forwards,  and  thus  slightly  retroverts   the  fundus.      To  facilitate  its 
introduction  the  bar  moves  on  a  hinge  so  that  it  may  be  brought  parallel 
with  the  pessary  as  it  is  passed  in,  while  a  concealed  india-rubber  spring 


FIG.  208. 
THOMAS'  ANTEVERSION  PESSARY. 

brings  it  into  place  when  it  is  within  the  vagina.  The  patient  requires 
careful  watching  after  its  introduction,  as  it  is  liable  to  set  up  pelvic 
inflammation.  Several  cases  are  recorded  by  Thomas  of  benefit  derived 
from  wearing  such  a  pessary. 

We  have  described  anteversion  as  one  of  the  displacements  of  the 
uterus.  The  student  should  note,  however,  that  anteversion  is  in  itself 
not  a  lesion  but  one  of  the  "physical  signs"  of  metritis,  chronic  pelvic 
peritonitis,  or  pregnancy.  It  is  improbable  that  the  mere  ante  vision 
of  the  uterus  causes  any  distress.  The  ordinary  statement  that 
uterus  when  anteverted  presses  on  the  bladder,  is  open  to  the  fatal 
criticism  that  the  uterus  always  presses  on  the  bladder ;  while,  so  far 
as  mere  weight  is  concerned,  there  are,  in  the  majority  of  cases,  no 
special  symptoms  referable  to  the  anteversion  of  early  pregnancy.  Any 
enthusiastic  believer  in  anteversion  pessaries  is  bound  to  insert  them  in 
all  cases  of  early  pregnancy.  Anteversion  is  thus  gradually  ceasing  to 
be  considered  among  uterine  displacements. 


360  AFFECTIONS   OF   UTERUS. 

RETRO  VERSION. 
PATHOLOGY   AND   ETIOLOGY. 

Physio-  Physiological  retroversion  occurs  whenever  the  bladder  is  fully  dis- 

Retro-        tended  (v.  fig.  42).     This  is  distinguished  from  the  pathological  con- 
version,     dition  by  the  fact  that  it  is  transient,  and  ceases  when  the  bladder  is 

emptied. 

Patho-  Pathological  retroversion  is  found  under  the  following  conditions. 

Retro-  !•  It  occurs  congenitally — which  we  assume  when  we  find  on  examin- 

version.  ing  a  virgin  or  nullipara  the  uterus  retroverted  and  either  no  symptoms 
or  a  history  of  symptoms  going  back  to  puberty.  This  is  by  no  means 
a  rare  condition  in  virgins,  as  Kiistner  found  this  in  21°/o  of  private  and 
1 3°/0  of  hospital  cases  of  backward  displacement ;  and  Graily  Hewitt  in 
23°/o  of  cases  (60  out  of  259)  noted  in  his  private  practice  during 
thirteen  years. 


FIG  209. 

UTERUS  RETROVERTED  AND  BOUND  BACK  BY  PERITONITIC  ADHESIONS  ( WinckeV).    aa  adhesions  ; 
6  bladder  ;  v  vagina  ;  u  uterus  ;  r  rectum  (J). 

2.  During  the  first  days  of  the  puerperium  the  uterus  lies  retroverted, 
or  at  least  retroposed.     The  weight  of  the  uterus  and  the  laxity  of  its 
attachments  make  it  occupy  this  position  when  the  patient  is  recum- 
bent, 

3.  It  is  produced  by  the  mechanism  of  prolapsus  uteri  (v.  Section 
VII.).     The   axis   of  the   uterus   changes  its  direction  as   the   organ 
descends. 

4.  It  is  also  of  importance  as  a  stage  in  the  production  of  retroflexion — 
the  most  frequent  and  important  displacement  which  calls  for  treat- 
ment.    The  uterus  becomes  retroverted,  and  then  acquires  a  backward 
flexion. 

5.  Chronic  peritonitis  producing  obliteration  of  the  pouch  of  Douglas, 


RETRO  VERSION.  361 

and  cicatricial  bands  which  drag  the  uterus  backward,  maintain,  if  they  do 
not  produce,  retroversion — :as  is  beautifully  shown  in  the  accompanying 
preparation  from  Winckel's  Atlas  (fig.  209). 
The  chief  causes  of  retroversion  are  : — 

1.  A  sudden  straining  effort,  or  a  violent  blow  (a  very  difficult 

cause  to  establish)  ;l 

2.  Non-return  of  the  uterus  to  its  normal  form  and  position 

during  the  puerperium  ; 

3.  Inflammatory  action  behind  the  uterus,  producing  adhesions 

in   the  pouch  of  Douglas ;  or  cicatrisation  of  the  anterior 
vaginal  wall.2 

SYMPTOMS. 

The  symptoms  of  retroversion  are  the  same  as  those  found  in  retro- 
flexion,  to  be  presently  described.  When  it  arises  during  the  puerperium, 
a  late  flooding — two  to  three  weeks  after  labour — is  sometimes  a  pro- 
minent symptom ;  or  there  is  a  daily  loss  of  blood  in  small  quantities 
whenever  the  patient  rises  and  goes  about  (FritscK). 

DIAGNOSIS. 

On  vaginal  examination,  the  cervix  is  low  down  in  the  pelvis  and  the 
os  looks  downwards  and  forwards.  The  finger  feels  the  supra-vaginal 
portion  of  the  cervix  through  the  posterior  fornix  and  may  be  able  to 
reach  the  fundus,  but  the  posterior  surface  is  straight — there  is  no  angle. 

On  bimanual  examination,  the  hands  can  meet  in  the  anterior  fornix  Bimanual 
with  nothing  but  the  vaginal  and  abdominal  walls  between  them.     It  version.0 
is  difficult  to  make  out  the  body  of  the  uterus.    We  may  try  to  do 
this  in  two  ways.     First,  with  one  finger  in  front  of  the  cervix  and  the 
other  behind  it,  lift  the  uterus  upwards  towards  the  abdominal  walls ; 
the  hand  placed  on  the  abdomen  will  feel  the  anterior  surface  of  the 
body  of  the   uterus  moving  under  it.     Second,    tilt  the   cervix   well 
forwards  with  the  index  finger  in  the  vagina,  and  thus  increase  the 
retroversion ;  the  middle  finger  will  feel  the  body  of  the  uterus  through 
the  posterior  fornix. 

The  rectal  examination  is  of  great  service  here.  The  sound  will  pass 
as  in  fig.  86. 

The  differential  diagnosis  is  the  same  as  in  retroflexion.  The  only 
point  requiring  special  notice  here  is  that  we  may  have  a  retroversion 
with  an  anteflexion  high  up.  Cases  of  anteflexion  due  to  cicatrisation 
of  the  utero-sacral  ligaments  are  often,  from  the  backward  direction  of 
the  cervix,  diagnosed  as  a  retroversion  (v.  p.  350). 

1  Graily  Hewitt  says  that  in  58  cases  of  backward  displacement  in  virgins,  nearly  one-half  (28  cases) 
traced  their  symptoms  back  to  a  severe  fall,  accident,  or  strain  ;  but  this  does  not  establish  any  of 
these  as  the  cause. 

-  This  acts  by  drawing  the  cervix  forwards.  Murdoch  Cameron  mentions  a  case  where  after  division 
of  a  bridle  on  the  anterior  vaginal  wall,  the  retroverted  uterus  became  normal. — Glas.  Med.  Journ. 
1887,  p.  420. 


362  AFFECTIONS   OF   UTERUS. 

TREATMENT. 

This  consists  in  (1)  removing  existing  inflammation;  (2)  replacement 
of  the  uterus,  when  not  fixed  by  adhesions ;  (3)  retention  of  it  in  its 
normal  position  by  pessaries :  these  will  all  be  considered  under  retro- 
flexion.  Congenital  cases  should  be  left  alone. 

When  adhesions  are  present,  it  is  better  not  to  interfere ;  or  we  may 
be  content  with  supporting  the  retroverted  uterus  with  a  pessary. 

RETROFLEXION. 

For  convenience  this  condition  is  usually  called  "Retroflexion,"  to 
distinguish  it  from  "  Retroversion  "  already  described  ;  strictly  speaking, 
the  condition  is  RETROVERSION  +  RETROFLEXION. 

PATHOLOGY. 

The  pathological  changes  in  the  position  and  structure  of  the  organs 
in  the  pelvis  consequent  on  retroversion  +  retroflexion,  can  be  learned  only 


FIG.  210. 

EXTREME  RETROFLEXION  OF  UTERUS  (Barnes). 

from  sections  made  with  the  organs  in  situ.  An  exact  knowledge  of 
these  changes  is  very  desirable,  as  this  displacement,  with  its  accom- 
panying complex  train  of  symptoms,  is  one  of  the  most  important  which 
come  under  the  notice  of  the  gynecologist. 

The  following  facts  are  based  more  on  clinical  examination  than  on 
pathological  study.  The  changes  in  the  various  structures  will  be  con- 
sidered separately  and  shortly  in  a  typical  case  of  retroflexion  in  a 
multipara. 

The  cervix  is  directed  downwards  and  forwards,  or  directly  downwards 
(v.  fig.  212).  We  observe  clinically  that  it  is  much  more  easily  reached. 
This  is  due  partly  to  the  alteration  in  its  direction  and  position  (being 


RETROFLEXION.  363 

nearer  the  symphysis  pubis  it  is  more  within  reach),  partly  to  the  sinking 
down  of  the  uterus  as  a  whole  in  the  pelvis.  The  os  is  patulous, 
because  retroflexion  usually  implies  previous  parturition.  If  deeply 
fissured,  it  may  form  a  gaping  cleft  which  readily  admits  the  tip  of  the 
finger.  There  is  often  ectropium  and  cervical  catarrh.  Sometimes 
there  is  marked  hypertrophy  of  the  posterior  lip,  so  that  it  is  mistaken 
for  the  projection  of  the  whole  vaginal  portion. 

The  uterus  is  flexed  on  itself,  so  that  the  fundus  lies  in  the  pouch  of 
Douglas,  the  depth  to  which  the  fundus  descends  and  the  acuteness  of 
the  angle  of  flexion  varying  in  different  cases  (v.  figs.  210  and  212).  If 
the  condition  of  the  uterine  walls  offers  no  resistance  to  flexion,  the 
intra-abdominal  pressure  will  tend  to  drive  the  fundus  downwards  till 
equilibrium  is  maintained  —  that  is,  till  the  fundus  rests  in  the  bottom 
of  the  pouch  of  Douglas.  In  retroflexion,  there  is  no  counteracting 
force  operating  from  below  similar  to  that  of  the  distending  bladder  in 
anteflexion. 

The  size  of  the  uterus  is  increased,  and  its  cavity  measures  more  than  Condition 
two  and  a  half  inches.     Since  the  flexion  generally  occurs  while  t 


uterus  is  still  enlarged  through  subinvolution,  it  is  difficult  to  sayEetro- 
whether  this  hypertrophy  arises  as  the  direct  result  of  the  displacement 
or  through  its  interfering  with  the  process  of  involution.  Whatever 
the  cause  of  this  hypertrophy  is,  its  effect  is  to  interfere  with  the 
natural  cure  of  the  displacement.  The  thickness  of  the  uterine  walls 
at  the  angle  of  flexion  varies  in  different  cases.  Sometimes  neither  wall 
is  atrophied  at  the  point  of  flexion  (fig.  210).  Barnes  says  that 
according  to  his  clinical  experience  this  is  the  usual  condition.  On  the 
other  hand,  Fritsch  states  that  he  has  found  marked  thinning  of  the 
posterior  wall  at  the  angle  of  flexion.  It  is  interesting  to  note  that  in  a 
case  of  congenital  retroflexion  (see  fig.  211)  described  by  Huge  it  is  the 
anterior  wall  which  is  atrophied  at  the  angle.  The  mucous  membrane 
of  the  uterus  is  generally  in  a  condition  of  chronic  catarrh. 

The  microscopic  changes  consist  in  a  dilated  condition  of  the  blood- 
vessels, with  increase  of  connective  tissue  —  the  appearances  produced 
by  long-continued  passive  congestion.  At  the  point  of  flexion,  however, 
an  opposite  condition  has  been  described  ;  the  blood-vessels  were  com- 
pressed and  the  tissues  atrophied. 

The  ovaries  follow  as  a  rule  the  displaced  fundus,  the  thin  infundibulo-  Ovaries  in 
pelvic  ligament  stretching  more  readily  than  the  ovarian.     The  position  ^fon 
of  the  ovaries  will,  however,  depend  on  the  effects  of  peritonitic  adhe- 
sions, which  may  fix  them  in  any  position.     Sometimes  we  feel  them 
below  the  fundus  in  the  pouch  of  Douglas.     They  are  frequently  enlarged 
and  tender  on  pressure. 

The  bladder  is  not  necessarily  altered  in  position,  but  has  no  longer  Bladder 

mi  •     i  -i     •       i  TI  j    •    in  Eetro- 

the  uterus  resting  upon  it.     The  utero-vesical  pouch  is  obliterated  mflexjon> 


364 


AFFECTIONS  OF  UTERUS. 


cases  of  well-marked  retroflexion.  The  ureters  are  often  compressed  or 
bent,  which  leads  to  dilatation  ;  frequently  they  are  found  dilated  to  the 
thickness  of  the  finger.  Fritsch  observed  in  one  case  the  left  ureter 
obliterated  by  a  mass  of  cicatricial  tissue,  and  the  corresponding  kidney 
changed  into  a  sac  full  of  white  atheromatous  debris. 

The  rectum  may  have  the  retroflexed  fundus  pressing  against  its 
anterior  wall. 

The  peritoneum  is  altered  in  its  normal  relations  as  follows.  The 
broad  ligaments  have  their  surfaces  reversed,  that  is  to  say,  the  anterior, 
which  was  formerly  inferior,  is  now  superior ;  from  their  attachments, 
they  offer  no  obstacle  to  retroflexion.  The  utero-vesical  pouch  neces- 
sarily disappears.  The  pouch  of  Douglas  must,  on  the  other  hand,  be 


FIG.  211. 

CONGENITAL  RETROFLEXION  (Ruffe).    Note  the  thinning  of  the  anterior  wall  of  the  uterus. 

distended  by  the  fundus  uteri  ;  this  implies  stretching  of  the  utero-sacral 
ligaments  associated  with  the  alteration  in  position  of  the  cervix. 

The  pelvic  nerves  are  occasionally  affected,  as  shown  by  weakness  in 
the  lower  limbs.  This  loss  of  power  must  be  produced  reflexly ;  from 
the  anatomical  relations,  the  retroflexed  fundus  cannot  compress  the 
motor  nerves  of  the  sacral  plexus  as  is  sometimes  affirmed. 

ETIOLOGY. 

Retroflexion  is,  according  to  Frankel's  recent  statistics,  more  common 
than  retroversion, l  As  a  congenital  condition,  it  is  not  nearly  so 

1  In  1882-85  he  treated  930  retrodeviationa  of  uterus  of  which  645  were  retroflexions  and  291 
retroversions. 


RETROFLEXION.  365 

frequent  as  auteflexion.  It  is  more  common  in  multipart  than  in 
nulliparse,  because  the  etiology  is  specially  related  to  the  puerperal 
condition.  In  this  condition  the  uterus  is  enlarged  and  heavy  and 
its  walls  are  soft.  The  ligaments  are  lax,  and  the  tissues  of  the 
pelvic  floor  have  been  recently  stretched  and  have  not  recovered  their 
tone.  Through  the  distention  of  the  bladder,  the  uterus  is  often 
thrown  into  a  retroverted  position. 

We  sometimes  find  on  examining  a  patient  shortly  after  her  confine- 
ment that  the  uterus  is  lying  back  in  the  pelvis  even  though  the  bladder 
be  not  distended  ;  we  may  thus  suppose  that  the  intra-abdominal pressure 
(which,  when  the  uterus  is  in  its  normal  position,  is  directed  upon  its 
posterior  surface)  comes  now  to  act  on  the  anterior  surface  and  drives 
the  fundus  backwards  and  downwards.  If  the  uterine  tissue  is  soft 
enough  to  allow  the  fundus  to  be  fixed  on  the  cervix,  such  a  flexion  will 
gradually  take  place  when  the  patient  makes  straining  efforts.  Apart 
from  this,  the  dorsal  posture  and  the  common  practice  of  tight  bandaging 
after  confinement  will  favour  backward  displacement  of  the  fundus.  If 
the  patient  rise  too  soon  while  the  uterus  is  still  large  and  heavy  and  the 
uterine  supports  correspondingly  lax  and  weak,  the  tendency  to  displace- 
ment is  increased. 

The  cause  of  retroflexion  in  nulliparse  is  obscure. 

SYMPTOMS. 

The  following  are  the  more  important  local  symptoms  : —  Local 

Weakness  in  the  back,  Symptoms 

....  <«  Dysmen- 

Symptoms  of  chronic  pelvic  peritonitis,  orrhcea. 

Painful  defalcation ; 

Leucorrhoea, 
Dysmenorrhoea, 
Menorrhagia ; 

Sterility, 
Abortion. 

In  long-standing  cases,  there  may  follow  the  train  of  general  constitu 
tional  symptoms  consequent  on  chronic  uterine  disease. 

The  symptoms  are  arranged  in  three  groups : — the  first,  including  those 
which  are  more  or  less  continuous ;  the  second,  those  which  are  within 
the  menstrual  period,  variable  or  periodic ;  the  third,  those  connected 
with  the  function  of  reproduction. 

The  connection  between  the  symptoms  present  in  cases  of  retroflexion 
and  the  displacement  itself  has  given  rise  to  much  discussion  and 
difference  of  opinion ;  and  here  we  must  emphasize  what  was  said  on 
page  346  that  the  symptoms  are  not  due  to  the  lesion  immediately  but 


366 


AFFECTIONS  OF  UTERUS. 


to  other  pathological  changes  consequent  on  or  associated  with  it. 
Herman1  would  refer  the  symptoms  in  displacements  entirely  "  to 
weakness  and  over-stretching  of  the  muscular  and  ligamentous  tissues 
which  support  the  uterus,"  but  we  cannot  thus  ignore  chronic  metritis 
and  endometritis  and  the  disturbances  of  menstruation  and  repro- 
duction. On  the  other  hand,  in  judging  of  the  symptoms  of  retro- 
flexion  we  must  keep  before  us  Vedeler's2  statistics,  who  found  in  40  p.c. 
of  cases  of  retroflexion  no  symptoms,  and  concludes  that  every  degree 
of  retroflexion  may  exist  either  with  or  without  symptoms. 

Weakness  in  the  back  is  the  most  common  complaint.  It  may  amount 
to  actual  pain,  which  is  aggravated  on  muscular  exertion  and  generally 
at  the  menstrual  periods.  The  symptoms  of  chronic  pelvic  peritonitis 
are  usually  present ;  the  feeling  of  weight  and  discomfort  in  the  pelvis  is 
sometimes  due  to  the  stretching  of  old  adhesions.  The  importance  of 
pelvic  inflammation,  fixing  the  uterus  in  its  abnormal  position  and  pre- 
venting its  replacement,  we  shall  consider  under  treatment.  Painful 
defalcation  with  tenesmus  is  explained  by  the  relation  of  the  loaded 
rectum  to  the  retroflexed  uterus  ;  irritation  from  pressure  of  the  fundus 
against  the  wall  of  the  rectum  may  produce  straining  efforts,  but  this 
is  very  rare. 

The  leucorrhcea  is  due  to  chronic  inflammation  of  the  mucous  mem- 
brane. As  the  result  of  the  displacement,  there  is  passive  congestion  of 
all  the  tissues  of  the  uterus ;  this  leads  in  the  first  instance  to  a  simple 
hypersecretion  of  mucus,  which  gradually  passes  into  chronic  inflamma- 
tion. The  mucous  secretion  is  more  marked  immediately  after  the 
increased  congestion  of  the  menstrual  period  ;  but,  gradually,  it  spreads 
itself  over  the  intermeustrual  period.  Dysmenorrhcea  is  not  so  frequent 
a  symptom  here  as  in  anteflexion ;  the  explanation  is,  on  the  mechanical 
theory,  that  retroflexion  usually  occurs  in  multipart  where  the  cervical 
canal  is  patulous.  Menorrhagia  forms  one  of  the  more  prominent 
symptoms ;  it  is  due  partly  to  the  chronic  inflammation  of  the  mucous 
membrane,  partly  to  obstruction  to  the  return  of  the  blood  from  the 
uterus. 

The  reproductive  function  is  variously  and  seriously  affected.  This  is 
brought  under  our  notice  when  retroflexion  occurs  in  one  who  has  already 
been  pregnant,  and  presents  an  obstacle  to  conception  or  at  least  to  the 
growth  of  a  fertilised  ovum  in  the  uterus.  Sometimes  a  patient  tells  us 
that  she  had  a  child  several  years  ago  ;  that  she  has  suffered  from  pain  in 
the  back,  leucorrhoaa,  and  irregular  menstruation  since  that  time  and  has 
never  conceived  again.  With  this  history,  we  may  find  retroflexion  of 
the  uterus  although  often  it  is  the  tubes  that  are  at  fault. 

The  sterility  may,  of  course,  be  due  to  a  variety  of  causes — the  altered 

'  The  Pathological  Relationship  of  Uterine  Displacements :  Brit.  Med.  Jour.,  1S8S.  I.,  p.  1213. 
2  Retroflexio  Uteri :  Archiv  f.  Gyn.,  Bd.  XXVIII.,  S.  228. 


RETROFLEXION,  367 

position  of  the  cervix,  the  increased  mucous  secretion,  obstruction  of  the 
Fallopian  tubes,  malposition  of  the  ovaries.  We  cannot  therefore  be 
sure  of  curing  the  sterility  by  replacing  the  uterus,  although  we  fre- 
quently find  that  the  patient  does  conceive  shortly  after  this  treatment. 
After  conception  has  taken  place,  there  is  the  further  risk  of  abortion; Abortion 
with  a  history  of  repeated  abortion,  we  sometimes  find  retroflexion.  Con-j?  ^etro- 
ception  probably  often  takes  place  in  a  retroflexed  uterus,  which  after- 
wards may  right  itself  so  that  pregnancy  goes  on  to  the  full  time.  Abor- 
tion is  due  to  the  inability  of  the  uterus  thus  to  right  itself,  or  to  the 
pathological  condition  of  the  mucous  membrane  which  prevents  the 
ovum  from  becoming  securely  attached.  When  abortion  does  not 
occur  and  the  pregnant  uterus  does  not  straighten  itself  so  as  to  grow 
upwards  into  the  abdomen,  it  enlarges  without  the  undoing  of  the 
flexion ;  in  this  case  it  will  expand  more  and  more  into  the  hollow  of 
the  sacrum  and  become  wedged  below  the  promontory.  This  constitutes 
Retroflexion  of  the  Gravid  Uterus. 

DIAGNOSIS. 

On  vaginal  examination  the  cervix  is  felt  low  down  in  the  pelvis,  the 
cause  of  which  has  been  explained  under  Pathology.  The  os  looks 
directly  downwards.  A  firm  round  body  is  felt  in  the  posterior  fomix, 
continuous  with  the  cervix  uteri  but  separated  from  it  by  a  groove  more 
or  less  distinctly  marked  according  to  the  amount  of  flexion.  Place 
the  forefinger  on  the  cervix,  and  the  middle  finger  on  this  body ;  on 
moving  the  former,  the  latter  moves  with  it. 

But  a  fibroid  tumour  of  the  posterior  wall  would  produce  similar  con- 
ditions; therefore  make  the  bimanual  examination.  First  place  the 
vaginal  fingers  in  the  anterior  fornix  and  make  pressure  with  the  external 
hand  until  the  fingers  of  both  hands  meet ;  there  is  nothing  between 
them  except  the  abdominal  and  vaginal  walls,  the  fundus  is  therefore  . 
not  to  the  front.  Now  put  the  vaginal  fingers  into  the  groove  behind 
the  cervix,  or,  better  still,  lay  hold  of  the  cervix  with  the  index  finger 
in  front  of  it  and  the  middle  finger  in  the  groove  behind  (see  fig.  212), 
and  lift  up  the  uterus  as  high  in  the  pelvis  as  possible ;  make  pressure 
with  the  external  hand  until  the  cervix  lies  fairly  between  the  hands ; 
the  upper  surface  of  the  uterus  is  felt  to  curve  backwards.  In  a  favour- 
able case  (with  lax  abdominal  walls)  we  can  do  the  bimanual  examination 
on  a  still  deeper  plane,  and  get  both,  hands  to  meet  behind  or  at  least 
fairly  embrace  the  retroflexed  fundus.  Having  ascertained  that  the 
fundus  uteri  is  retroflexed,  we  ask  ourselves  whether  it  be  fixed  or  mov- 
able— whether  it  can  be  replaced  or  not.  In  making  our  diagnosis  we  at 
the  same  time  take  a  step  towards  treatment.  To  ascertain  the  mobility 
of  the  fundus,  make  steady  pressure  on  it  upwards ;  observe  whether  it 
gives  way  before  the  finger,  and  whether,  on  its  yielding,  the  flexion 


368 


AFFECTIONS  OF   UTERUS. 


Rectal 
examina- 
tion in 
Retro  - 
flexion. 


Uterine 
Sound  in 
Retro- 
flexion. 


becomes  undone  or  the  uterus  simply  rotates  as  a  whole ;  note  also 
whether  this  manipulation  causes  pain. 

The  rectal  examination  has  this  advantage,  that  the  finger  passes 
upwards  over  the  free  surface  of  the  fundus  without  displacing  it.  It 
is  indispensable  in  cases  where  the  rigidity  of  the  abdominal  walls  pre- 
vents our  getting  the  uterus  between  the  hands  in  the  Bimanual.  The 
drawing  down  of  the  uterus  with  the  volsella  is  an  additional  help 
in  such  cases,  as  it  enables  the  finger  in  the  rectum  to  reach  the 
fundus. 

The  sound  confirms  the  diagnosis  in  doubtful  cases,  and  tells  us 
further  whether  the  retroflexed  uterus  is'  enlarged.  Before  using  the 
sound,  we  must  palpate  the  uterus  carefully  to  ascertain  that  it  is  not 
becoming  enlarged  with  a  growing  ovum  and  inquire  as  to  the  patient's 


FIG.  212. 

DIAGNOSIS  OF  RETKOFLEXION  BY  BIMANUAL  EXAMINATION. 


menstruation.  We  curve  the  sound  to  correspond  with  the  degree  of 
flexion  ascertained  on  bimanual  examination.  If  introduced  with  the 
concavity  directed  backwards,  it  passes  into  the  uterine  cavity  without 
our  having  to  make  the  rotation  (v.  fig.  86) ;  through  the  posterior  fornix, 
we  feel  the  end  of  it  in  the  retroflexed  fundus ;  it  usually  passes  in 
beyond  the  two  and  a  half  inches.  We  can  also  learn  from  the  sound 
whether  the  uterus  can  be  replaced  or  not ;  but  it  is  better  to  get  the 
information  from  the  bimanual  examination.  The  sound  is  of  most  use 
in  differential  diagnosis. 


RETROFLEXION.  369 

Differential  diagnosis.     The  following  are  the  conditions  arranged  in  Differential 
the  order  of  frequency,  which  might  be  mistaken  for  retroflexion  : —         of  ifT^8 

flexion, 
Fteces  in  the  rectum  ; 

(  Peritonitis, 

Pelvic  deposit  in  the  pouch  of  Douglas  -^  Hsematocele, 

(  Carcinoma ; 

Cellulitis  behind  the  cervix ; 

Myoma  of  the  posterior  wall ; 

Prolapsed  ovary  or  small  ovarian  tumour. 

Fcecal  matter  in  the  rectum  gives  rise  to  difficulty  only  on  superficial  from  load- 
examination.     We  should  always  decline  to  give  an  opinion  as  to  the6  ilectum> 
condition   of  the   pelvic  organs  when  the  rectum   is  loaded.     If  this 
be   attended   to,   no   mistake   in  diagnosis   will  be   made   under  this 
head. 

Pelvic  deposit  in  the  pouch  of  Douglas  gives  rise  to  more  difficulty,  from 
because  it  may  closely  simulate  the  condition  found  in  retroflexion — 'a 
body  felt  through  the  posterior  fornix  and  moving  along  with  the  cervix.' 
Such  a  deposit  will  be  proved  not  to  be  the  fundus  uteri  by  our  finding 
the  latter  in  another  position.  If  inflammation  is  present,  it  is  difficult 
to  make  the  examination  necessary  to  ascertain  this ;  we  may  not  be 
justified  in  using  the  sound  just  where  it  would  give  us  the  desired 
information  :  such  cases  present  great  difficulty  in  diagnosis,  and  the  true 
condition  can  only  be  ascertained  on  repeated  examination  or  after  the 
inflammation  has  subsided. 

Cellulitis  behind  the  cervix  is  rarely  present  in  such  a  form  as  to  give  from 
rise  to  a  mistake  in  diagnosis,  unless  the  inflammation  renders  the  neces-          ltls' 
sary  examination  difficult. 

A  myoma  projecting  posteriorly  from  the  lower  segment  of  the  uterus  from 
resembles,  in  form  and  firmness,  the  retroflexed  fundus.     On  bimanual Myoma' 
examination,  however,  we  find  that  we  have  between  the  hands  a  larger 
body  than  the  uterus  alone.     The  fundus  may  also  be  felt  to  the  front, 
and  distinct  from  the  tumour.     To  ascertain  its  position,  it  is  best  to 
make    the    bimanual   examination   with    the    sound  in    the    cavity    of 
the  uterus.     Fig.   204   shows   the   information   given   by  the   sound, 
if  we   suppose   that  the   structure   to   the   left   of  the   figure   is   the 
rectum.     A  fibroid  tumour  accompanied  by  inflammation  presents  great 
difficulty. 

If  the  ovary  be  prolapsed,  enlarged  through  inflammation,  and  adherent  from 
to  the  posterior  aspect  of  the  uterus,  it  simulates  (on  vaginal  examination)  lapg"e^ 
the  retroflexed  fundus.     So  also  does  a  small  ovarian  tumour  lying  inOvai7- 
the  pouch  of  Douglas,  though  it  is  softer  and  more  elastic  than  the 
uterus.     The  bimanual  examination,  supplemented  if  necessary  by  the 
2  A 


370 


AFFECTIONS  OF  UTERUS. 


Possibility 
of  cure  of 
Retro - 
flexion. 


use  of  the  sound  and  the  drawing  down  of  the  uterus  with  the  volsella, 
enables  us  to  ascertain  the  exact  position  of  the  fundus  and  its  relation 
to  the  tumour. 

PROGNOSIS. 

The  prognosis  depends  upon  the  mobility  of  the  uterus,  and  the  possi- 
bility of  replacing  it.  It  is  always  less  favourable  where  inflammation 
is  present ;  though  we  have  seen  considerable  exudations  become  after  a 
time  absorbed,  and  the  uterus  again  movable  so  that  it  could  be  replaced. 
As  regards  the  probability  of  future  conception,  our  statements  should 
be  guarded ;  though  the  probabilities  are  increased  if  we  can  replace 
the  uterus. 

Whether  a  permanent  cure  of  the  displacement  (so  that  the  uterus 


FIG.  213. 
REPOSITION  CJF  THE  RETEOFLEXED  UTERUS  BY  THE  FINGER  IN  THE  RECTUM. 

will  keep  its  normal  position  after  the  instrument  is  removed)  is  often 
effected,  we  have  not  much  definite  information.  A  priori,  we  should 
not  expect  that  the  stretched  utero-sacral  ligaments  would  readily 
become  shortened  again  unless  a  pregnancy  supervene.  The  curability 
of  the  retroflexion  depends,  according  to  Munde,  on  the  recency  of  the 
displacement ;  "  recent  displacements  of  any  variety  are  the  only  cases 
which  offer  a  fair  chance  of  complete  recovery  by  any  of  the  mechanical 
means  at  our  disposal."  The  length  of  time  during  which  a  pessary 
must  be  worn  so  as  to  effect  a  cure  of  recent  puerperal  retroflexion  is, 
according  to  Munde",  six  months  to  a  year. 


RET  HO  FLEXION.  371 


TREATMENT. 

This  consists  of  two  parts  : — 

1.  Replacement  of  the  retroflexed  uterus; 

2.  Retention  of  it  in  its  normal  position  by  suitable  means. 

The  first  question  which  suggests  itself  on  discovering  a  retroflexion 
is,  whether  we  can  replace  the  uterus ;  this  has  been  ascertained  at  the 
same  time  as  we  made  the  diagnosis. 

The  two  obstacles  to  treatment  are  the  presence  of  existing  inflamma- 
tion and  the  fixation  of  the  uterus  in  its  abnormal  position.  The  former 
must  be  treated  by  blistering,  hot- water  injections,  and  the  use  of  the 
glycerine  plug ;  these  may  have  to  be  continued  for  a  month  or  more, 
and  then  we  may  attempt  the  reposition.  This  last  may  be  impossible 
through  the  firmness  of  the  flexure  or  the  presence  of  old  adhesions. 
It  must  be  left  to  the  operator  to  determine  how  much  force  he  is 
justified  in  employing.  Sometimes  it  is  necessary  to  put  the  patient 
under  chloroform.  In  cases  where  we  cannot  replace  the  uterus,  benefit 
may  be  derived  from  simply  supporting  it  with  a  pessary. 

Schultze  recommends  the  breaking  of  adhesions  by  recto-abdominal 
manipulation  under  an  anaesthetic — not  aiming  at  forcible  reposition, 
but  purely  at  the  loosening  of  the  adhesions  through  careful  bimanual 
stretching. 

Method. — Bladder  and  rectum  are  empty  ;  dorsal  posture,  thighs  flexed  and  abducted. 
Irrigate  the  rectum  with  warm  water.  "With  the  index  and  middle  fingers  in  rectum  and 
the  external  hand  grasping  the  fundus,  lift  the  uterus  carefully  up.  Slight  adhesions 
yield  to  pressure  of  fingers ;  broader  ones  are  stretched  by  the  ends  of  the  fingers, 
although  repeated  attempts  may  be  necessary.  A  pessary  introduced  after  reposition. 

He  also  attempts  to  replace  adherent  prolapsed  ovaries  in  same  way. 

Let  us  suppose  that  we  are  treating  a  case  suitable  for  reposition, 
after  inflammation  has  subsided. 

1.  Methods  of  Replacing  the  Retroflexed  Uterus. 

These  are  the  three  following  : — 

(1.)  By  bimanual  vagino-rectal  manipulation; 

(2.)  With  the  sound; 

(3.)  By  genupectoral  posture,  combined  with  traction  on  the  uterus 

with  the  volsella  and  (if  necessary)  pressure  on  the  fundus 

•with  the  finger  in  the  rectum. 

(1.)  The  bimanual  manipulation  is  the  safest  method,  and  can  be  at  Reposition 
once  proceeded  with  as  soon  as  we  have  diagnosed  the  pathological  °f  ^etr°- 
condition ;  owing  however  to  its  causing  more  discomfort  to  the  patient  Uterus  by 
it  is  not  so  much  used.     The  replacement  is  best  effected  with  the  index Bimanual- 


372 


AFFECTIONS  OF   UTERUS. 


finger  in  the  vagina  and  the  middle  finger  in  the  rectum.  If  with  both 
fingers  in  the  vagina  we  make  pressure  through  the  fornices,  we  simply 
push  the  uterus,  as  a  whole,  upwards.  With  the  finger  in  the  rectum, 
however,  we  get  behind  the  uterus  and  push  it  forwards.  Place  the 
patient  in  the  dorsal  position;  pass  the  fingers  into  the  vagina  and 
rectum,  as  in  the  accompanying  diagram  (fig.  213).  Make  steady 
gradual  pressure  on  the  posterior  surface  of  the  fundus  with  the  middle 


FIG.  214. 

REPLACEMENT  or  THE  UTERUS  WITH  THE  SOUND.    1,  2,  3,  the  successive  positions  of  the 
SOUND  and  of  the  UTERUS. 


finger.  Direct  the  pressure  to  one  side  of  the  middle  line,  so  as  to  keep 
the  fundus  clear  of  the  promontory  of  the  sacrum.  With  the  index 
finger  placed  in  front  of  the  cervix,  push  it  backwards  and  thus  rotate 
the  fundus  forwards.  Having  by  this  manoeuvre  brought  the  fundus 
uteri  to  the  front  (into  the  position  indicated  by  the  dotted  line  in  the 
diagram),  make  with  the  external  hand  steady  downward  pressure  so  as. 


RETROFLEXION.  373 

to  get  between  it  and  the  hollow  of  the  sacrum  and  thus  depress  the 
fundus  still  more  to  the  front.  A  glycerine  plug  is  now  placed  in  the 
vagina  to  keep  the  uterus  in  position.  The  plugging  should  be  chiefly 
in  the  anterior  fornix,  so  as  to  exert  upward  pressure  on  the  cervix  and 
thus  favour  the  tilting  of  the  fundus  forwards.  On  the  following 
day,  if  there  be  no  indication  of  inflammation,  a  pessary  may  be 
introduced. 

(2.)  Replacement  Avith  the  sound  has  the  advantage  that  it  causes  Replace- 
less  discomfort  to  the  patient;  it  is  therefore  the  method  generally thT 
employed.  We  may  have  the  sound  already  in  the  uterus  to  make  sure 
of  our  diagnosis,  and  (without  withdrawing  it)  we  can  proceed  at  once 
to  effect  the  reposition.  In  the  employment  of  force  we  require  to  be 
more  careful  than  in  the  bimanual  manipulation,  because  the  sound  gives 
us  greater  leverage,  pressure  is  being  made  on  the  mucous  membrane 
of  the  uterus,  and  there  is  not  the  same  delicate  sense  of  resistance  as 
when  the  finger  is  immediately  in  contact  with  the  uterus.  The  end  of 
the  sound  should  not  be  too  much  curved.  If  the  flexion  be  pretty 
acute,  so  that  the  sound  requires  to  be  well  curved  to  pass  easily  into 
the  body  of  the  uterus,  we  should  first  reduce  the  acuteness  of  the  flexion 
by  repeatedly  passing  in  the  sound  more  and  more  straightened.  Having 
by  this  means  partially  converted  the  retroflexion  into  a  retroversion,  we 
proceed  to  reposition  as  follows.  The  sound  lies  as  in  position  1  in  the 
figure  (fig.  214)  :  the  direction  of  the  handle  is  backwards,  and  the 
roughened  face  looks  to  the  back;  the  intra-uterine  portion  (1)  also  has 
the  curve  backwards.  Now  lay  hold  of  the  handle  loosely,  rather  allow- 
ing it  to  lie  between  the  fingers  than  grasping  it.  Carry  the  handle 
upwards  towards  the  patient's  right  buttock  (as  she  is  on  her  left  side) 
forwards  with  a  wide  sweep  and  downwards  again  towards  the  couch, 
the  shaft  describing  half  of  a  cone.  The  sound  thus  comes  to  lie  in 
position  2  in  the  figure  :  the  direction  of  the  handle  is  forwards,  and  the 
roughened  face  is  now  to  the  front ;  the  intra-uterine  portion  of  the 
sound  has  also  rotated,  so  that  the  curve  is  now  forwards,  but  the  uterus 
as  a  whole  is  still  to  the  back  (fig.  214,  2,  2).  Now  carry  the  handle  of 
the  sound  gently  and  slowly  backwards,  in  a  straight  line  towards  the 
perineum.  The  sound  now  lies  in  position  3  :  the  roughened  surface  is 
to  the  front,  and  the  handle  is  now  directed  backwards ;  the  fundus 
uteri  is  consequently  in  its  normal  position  (fig.  214,  3).  The  reason 
for  this  manipulation  is  evident.  If  we  rotated  the  handle  of  the  sound 
forcibly  round  its  long  axis  (bringing  it  at  once  from  position  1  to  3),  the 
intra-uterine  portion  would  describe  a  wide  curve  within  the  uterine 
body  and  probably  produce  laceration  of  the  mucous  membrane.  Before 
withdrawing  the  sound  we  make  sure  by  external  palpation  that  the 
fundus  uteri  is  to  the  front,  as  the  latter  is  more  easily  felt  when 
stiffened  by  the  sound.  After  withdrawal  of  the  sound,  the  uterus  must 


374 


AFFECTIONS  OF  UTERUS. 


be  kept  in  position  by  the  glycerine  plug  or  pessary.  Frequently  we 
find  that  the  uterus  falls  back  into  its  abnormal  position  as  soon  as  the 
sound  is  withdrawn  ;  in  such  cases,  the  pessary  should  be  slipped  in  over 
the  handle  of  the  sound  and  put  in  position  before  the  latter  is  with- 
drawn. 

Various  forms  of  uterine  repositors  have  been  devised  by  Sims  and 
others.  They  might  be  compared  to  a  sound  having  the  intra-uterine 
portion  jointed  to  the  stem,  on  which  it  can  be  rotated  antero-posteriorly 
by  a  suitable  mechanism.  They  are  not  of  such  practical  value  as  to 


FIG.  215. 

REPLACEMENT  or  THE  UTERUS  WITH  THE  VOLSELLA  AND  THE  FINGER  IN  THE  RECTUM  ;  the  patient 
is  in  the  genupectoral  position. 

require  further  description  here.     No  mechanism  can  equal  the  fingers 
in  nicety  of  action. 

(3.)  The  importance  of  the  genu-pectoral  posture  in  replacing  the 
retroflexed  uterus  has  been  brought  forward  by  H.  F.  Campbell.  On 
placing  the  patient  in  this  posture,  the  abdominal  contents  gravitate 
downwards  and  forwards;  this  displacement  withdraws  the  internal 
pressure  from  the  pelvic  floor,  so  as  to  subject  it  to  the  atmospheric 


RETROFLEXION. 


375 


pressure  from  without.     If  the  vaginal  orifice  be  now  opened,  the  vaginal 
cavity  becomes  distended  with  air ;  if  the  walls  are  lax,  the  cavity  may 
be  so  large  that  the  finger  reaches  the  cervix  with  difficulty.     The  posi- 
tion of  the  uterus  changes  j1  but  the  retroflexed  uterus  does  not  become  The  Retro- 
replaced,  as  Campbell  supposed.     It  moves  as  a  whole  near  the  sacrum ;  ?£xe<* 
and,  if  already  retroverted,  it  becomes  still  more  so.     To  effect  replace- in  Genu- 
ment,  we  must  either  push  the   fundus  forwards  or   draw  the  cervix  j^^ 
backwards.     It  is  best  to  combine  these  actions  ;  having  laid  hold  of  the 
cervix  with  the  volsella  per  vaginam,  we  draw  it  downwards  while  with 
the  index  finger  of  the  right  hand,  per  rectum,  we  press  the  fundus 
towards  the  bladder  (see  fig.  215).     This  method  of  reposition  is  only 
used  in  cases  of  retroflexion  of  the  gravid  uterus. 

Having  replaced  the  uterus  by  one  of  those  methods,  we  have  to 
retain  it  in  its  normal  position. 


FIG.  216. 

HODGE  PESSARY. 


FIG.  217. 

ALBERT  SMITH  PESSARY. 


FIG.  218. 

SIDE  VIEW  OF  ALBERT  SMITH 

PESSARY.     The  Hodge  is  similar,  but 

has  the  lower  curve  less  marked. 


2.  Methods  of  Retaining  the  Replaced  Uterus. 

The  retention  of  the  uterus  in  its  normal  position  is  effected  by  vaginal 
pessaries.  Of  these  the  best  forms  are  the  Hodge  or,  its  modification, 
the  Albert  Smith. 

The  material  of  which  they  are  made  is  vulcanite,  which  is  light  and  Material  of 
smooth  and  not  affected  by  vaginal  discharges.     To  bend  the  vulcanite, Pe 
the  pessary  should  be  placed  in  hot,  almost  boiling,  water.     It  is  thus 
made  pliable  and  can  be  moulded  to  the  desired  form,  but  becomes  firm 
again  on  placing  it  in  cold  water ;  this  is  also  effected  by  oiling  the 
pessary  and  heating  it  in  a  spirit  lamp.     Pessaries  are  also  made  o 

1  For  full  account  of  changes  produced  by  the  genu-pectoral  posture,  the  student  should  consult 
the  Atlas  of  the  "  Relations  of  the  Abdominal  and  Pelvic  Organs  in  the  Female  :  Simpson  and 
Hart,  1881. 


376 


AFFECTIONS  OF  UTERUS. 


gutta-percha,  which  has  the  advantage  of  being  easily  moulded ;  these 
cannot,  however,  be  worn  for  a  long  time,  as  the  gutta-percha  is 
absorbent  and,  retaining  the  secretions,  sets  up  irritation.  The  patient 
can  wear  one  for  a  few  weeks  till  we  see  that  it  fits  comfortably  and  is 
effective,  and  then  we  can  substitute  one  of  a  similar  form  made  of 
vulcanite.  Celluloid  pessaries  are  now  sometimes  used  instead  of 
vulcanite  ones. 

The  Hodge  The  form  of  the  Hodge  is  an  elongated  horse-shoe,  with  a  straight 
transverse  bar  joining  the  free  ends.  Seen  from  the  front  (fig.  216), 
it  has  a  curved  upper  end  which  is  adapted  to  the  posterior  fornix ;  the 
lower  end  consists  of  a  straight  bar  which  serves  to  keep  the  sides  apart, 


FIG.  219. 

INTRODUCTION  OF  PESSARY,  FIRST  STAGE. 

and  lies  under  cover  of  the  symphysis  pubis ;  the  external  angles  of  this 
end  are  rounded  to  prevent  their  cutting  the  vagina;  the  sides  run 
almost  parallel.  Seen  from  the  side  (fig.  218),  it  is  a  mould  of  the 
vaginal  slit;  there  is  an  upper  sacral  curve,  which  is  long  and  well- 
marked  ;  there  is  a  lower  pubic  one,  which  is  not  necessarily  present  or 
The  Albert  is  only  slightly  marked.  The  pessary  lies  so  that  the  concavity  of  the 
sacral  curve  looks  forward,  that  is  to  say,  the  upper  end  of  the  pessary 


RETROFLEXION. 


377 


(like  the  posterior  fornix  vagiuse)  curves  forwards.  The  Albert  Smith 
(fig.  217)  contracts  in  its  lower  half  to  a  more  or  less  beak-shaped  end  ; 
seen  from  the  side,  it  has  the  pubic  curve  more  marked  (fig.  218). 
Scientifically  it  is  the  more  correct  form,  because  the  posterior  wall  of 
the  vagina  is  narrower  below  than  it  is  above.  The  lower  end  should 
not  be  too  much  contracted,  otherwise  it  is  apt  to  interfere  with  married 
life ;  also  when  the  vaginal  orifice  is  wide,  it  favours  the  expulsion  of 
the  instrument.  A  second  modification  of  the  Hodge  is  recommended 
by  Thomas,  in  which  the  upper  bar  is  thicker,  the  sacral  curve  more 
pronounced,  and  the  whole  instrument  longer. 

The  choice  of  an  instrument  suitable  to  the  case  must  be  made.     The  Choice  of 

Hodge 
Pessary. 


FIG.  220. 
SECOND  STAGE  :  PESSARY  CARRIED  ON  BY  FINGER. 

pessary  should  be  narrower  and  shorter  than  the  posterior  vaginal  wall, 
so  that  it  produces  no  tension  when  it  is  in  position.  The  upper  bar 
should  be  of  such  a  size  that  it  can  be  passed  in  easily;  the  lower 
should  be  narrower  than  the  uppei-,  but  not  too  narrow  for  the 
reasons  given  above.  The  proof  of  a  good  fitting  instrument  is  that 
the  patient  does  not  feel  its  presence,  nor  should  it  interfere  with 
married  life. 

The  mode  of  introduction  of  the  pessary  demands  special  attention.     It 
is  important  that  this  apparently  simple  manoeuvre  be  effected  without  ^on  of 
causing  pain  to  the  patient.     From  the  fact  that  the  vulvar  orifice  ispessary. 


378  AFFECTIONS  OF  UTERUS. 

antero-posterior  while  the  cavity  of  the  vagina  is  transverse,  the  instru- 
ment must  be  introduced  with  its  plane  surface  horizontal  (the  patient  is 
supposed  to  be  on  the  side)  and  afterwards  rotated  so  that  this  comes  to 
be  vertical.  From  the  position  of  the  cervix,  the  instrument  is  very 
liable  to  run  into  the  anterior  fornix.  When  in  position  the  upper  end 
must  curve  forwards.  Having  oiled  the  instrument,  grasp  it  with  the 
lower  end  (the  square  end  in  the  case  of  the  Hodge,  the  narrower  end  in 
the  case  of  the  Albert  Smith)  between  the  finger  and  thumb  of  the  right 
hand.  Separate  the  labia  with  the  first  and  second  fingers  of  the  left 
hand ;  when  the  vaginal  orifice  is  narrow,  hook  back  the  fourchette  with 
one  finger  or  get  the  posterior  corner  of  the  end  which  is  being  intro- 
duced within  the  vaginal  orifice ;  and  press  back  the  perineum  with  it  so 


FIG.  221. 

PESSARY  in  situ  IN  THE  VAGINA,  ad  naturam.    a  perineum,  bb  pessary,  c  anterior  and  d  posterior 
vaginal  wall,  e  anterior  and /posterior  lip  of  cervix. 

that  the  anterior  corner  is  not  pushed  against  the  clitoris  or  vestibule. 
Now  push  the  pessary  backwards  in  the  axis  of  the  vagina  till  it  is  half 
within  the  cavity  (see  fig.  219),  and  rotate  it  so  that  the  concavity  of  the 
sacral  curve  looks  forwards.  Pass  the  index  finger  behind  the  instru- 
ment into  the  vagina,  and  place  the  tip  of  it  against  the  upper  bar ; 
carry  the  pessary  onwards,  keeping  the  upper  bar  well  against  the 
posterior  vaginal  wall  to  prevent  its  slipping  up  in  front  of  the  cervix 
(fig.  220). 

Hodge  6  The  position  and  action  of  the  pessary  when  in  situ  are  as  follows. 
Pessary  It  lies  exactly  adapted  to  the  vaginal  walls  (see  fig.  221);  the  upper 
in  situ.  end  being  in  the  posterior  fornix  behind  the  cervix,  the  lower  just  within 


RETROFLEXION. 


379 


the  vaginal  orifice.  It  is  kept  in  position  through  its  resting  on  the 
oblique  anterior  face  of  the  sacral  segment  of  the  pelvic  floor,  against 
which  it  is  compressed  by  the  posterior  face  of  the  pubic  segment. 

The  student  will  readily  understand  and  remember  the  position  of  the 
pessary  in  the  following  way.  Hold  the  hand  inclined  as  in  fig.  222, 
with  the  palm  slightly  inflexed.  It  resembles  the  posterior  vaginal  in 
the  following  points  : — (1)  It  is  broader  above  than  below  ;  (2)  it  curves 
forwards  above ;  (3)  from  its  obliquity,  it  allows  the  pessary  to  sit  on 
it.  Now  place  the  pessary  on  it.  It  will  only  lie  adapted  to  the  hand 
when  the  broad  end  is  above  and  the  upper  curve  is  directed  forwards. 

The  Hodge  pessary  does  not  act  as  a  lever;  that  is  to  say,  the  intra- Action  of 
abdominal  pressure  does  not  act  specially  on  the  lower  bar  and  depress  ^ 


FIG.  222. 

HAND  HOLDING  ALBERT  SMITH  PESSARY. 

it,  causing  the  superior  one  to  rise.  The  intra-abdominal  pressure  acts 
nearly  equally  on  both  bars,  of  which  fact  the  student  may  satisfy  him- 
self clinically.  Its  action  is  that  the  upper  bar  gives  a  point  d'appui  to 
the  posterior  fornix.  The  posterior  vaginal  wall  runs  round  the  upper 
bar  as  on  a  pulley,  and,  as  it  is  inserted  into  the  cervix,  the  latter  is 
thereby  drawn  upwards  and  the  fundus  thrown  forwards  (fig.  223).  The 
pessary,  therefore,  has  the  same  action  as  the  utero-sacral  ligaments,  if 
we  suppose  that  these  keep  the  cervix  backwards.  This  is  only  the 
action  in  the  case  of  a  retroverted  uterus  which  has  been  replaced.  A 
vaginal  pessary,  however,  gives  relief  even  though  we  may  not  be  able 
to  replace  the  uterus.  In  this  case  we  may  suppose  that  it  acts  by 


380 


AFFECTIONS   OF  UTERUS. 


supporting  the  uterus  as  a  whole,  thus  diminishing  tension  on  the  liga- 
ments and  passive  congestion. 1 

Another  way  of  showing  how  the  Hodge  pessary  acts  is  as  follows. 
With  the  patient  lying  on  her  left  side,  pass  the  index  finger  into  the 
posterior  fornix  vaginae  and  push  it  up  in  a  direction  parallel  to  the 
posterior  vaginal  wall.  This  necessarily  pulls  the  cervix  back,  and  thus 
the  fundus  is  kept  forward.  In  other  words,  if  the  cervix  be  thus  kept 
back  by  the  tension  of  the  finger  in  the  posterior  fornix,  the  uterus 
cannot  become  retroverted  although  the  fundus  may  become  retroflexed. 


FIG.  223. 

POSITION  AND  ACTION  OF  PESSARY. 

Now  if  a  Hodge  pessary  be  passed  into  position  and  held  by  the  hand, 
it  will  act  just  as  the  finger  does.  It  does  not  require  to  be  held,  how- 
ever, as  it  rests  on  the  oblique  sacral  segment  and  is  pressed  against  it 
by  the  pubic  segment  and  abdominal  viscera.  Note  that  the  pressure 

1  See  Granville  Bantock  on  The  Use  ami  Abuse  of  Pessaries,  London,  1884 ;  Hart  on  The  Structural 
Anatomy  of  the  Female  Pelric  Floor. 


RETROFLEXION.  381 

on  the  Hodge  is  at  right  angles  to  the  posterior  vaginal  wall ;  there  is 
no  side  to  side  pressure  on  the  instrument,  and  thus  it  does  not  require 
to  extend  from  side  to  side  of  the  vaginal  walls. 

The  after-watching  of  the  case  is  important.  The  patient  should  be 
instructed  to  return  in  two  days  to  see  that  the  instrument  is  in  place, 
and  to  return  at  once  if  it  causes  pain.  After  this  she  should  report 
herself  occasionally,  say  at  intervals  of  a  month,  when  examination  is 
made  to  ascertain  that  the  uterus  keeps  its  place.  If  she  uses  hot-water 
injections  occasionally,  it  is  not  necessary  to  remove  the  instrument  to 
clean  it  more  frequently  than  this.  After  the  pessary  has  been  worn  for 
some  months,  it  may  be  removed  to  see  if  the  uterus  remains  in  position 
without  it.  Sometimes  we  find  that  the  uterus  falls  back  again  into 
its  abnormal  position  as  soon  as  the  instrument  is  withdrawn  ;  in  such 
a  case,  it  must  be  introduced  again  and  may  have  to  be  worn  for  years. 


FIG.  224.  FIG.  225. 

SCHULTZE'S  PESSARY.  MEADOW'S  COMPOUND  STEM  PESSARY. 

Should  conception  occur,  the  pessary  may  be  worn  till  the  fourth  month, 
after  which  the  uterus  rises  above  the  brim  and  there  is  no  longer  reason 
to  fear  displacement. 

In  Germany,  Schultze's  pessary  (fig.  224)  is  the  one  in  general  use.     ItSchultze's 
has  the  form  of  a  figure  of  eight,  the  upper  ring  embracing  the  cervix.  Pessary< 
It  is  interesting  to  note  that  it  also  goes  on  the  principle  that  the  pessary 
acts  on  the  cervix,  not  the  body  of  the  uterus. 

In  some  cases  the  uterine  tissue  is  flaccid  at  the  angle  of  flexion,  and 
the  body  falls  to  the  back  or  front  as  if  it  were  jointed  to  the  cervix. 
Here  the  Hodge,  which  acts  on  the  body  through  the  cervix,  does  no 
good ;  the  intra-uterine  stem,  along  with  a  Hodge  which  has  transverse 
bars,  is  suitable  for  some  of  these  cases.  Wynn  Williams,  Meadows(fig.  225) 
and  Routh  have  devised  good  forms  of  pessary  on  this  principle. 


382  AFFECTIONS  OF   UTERUS. 

Their  use  has  recently  been  again  advocated  by  Routh, l  but  the  general 
opinion  of  gynecologists  in  this  country  is  against  intra-uterine  stem 
pessaries. 

Hodge's          From  what  has  been  said  on  the  action  of  the  Hodge  pessary,  it  is 

KooTonlv    evident  that  in  the  treatment  of  Retroversion  +  Retroflexion  the  version 

in  Retro-    alone  is  affected  by  the  pessary.     Whether  the  flexion  is  remedied  will 

depend  on  the  state  of  the  uterine  walls  and  the  effect  of  intra-abdominal 

pressure  upon  them. 

For  illustrative  examples  showing  the  value  of  pessaries  in  suitable 
cases,  the  student  may  consult  Bantock's  monograph,  or  Macan's  trans- 
lation of  Schultze. 

Operations  for  Retaining  the  Uterus  in  position. 

In  many  cases  pessaries  fail  to  keep  the  uterus  in  position,  and 
ingenuity  has  of  late  been  exercised  in  devising  operative  measures  for 
this.  These  must  be  held  as  sub  judice,  for  two  reasons  :  We  cannot  a 
priori  affirm  that  the  symptoms  were  due  to  the  displacement ;  and  the 
cases  have  not  been  followed  for  a  sufficient  number  of  years  to  judge  from 
their  results  alone  that  such  operations  are  called  for.  Three  methods 
of  acting  on  the  uterus  have  been  tried :  (a)  Through  the  vagina,  by 
causing  cicatrisation  to  pull  on  the  cervix ;  (6)  through  the  round  liga- 
ments, by  shortening  them  and  then  pulling  the  uterus  forwards ;  (c) 
through  peritoneal  adhesions,  by  tacking  the  fundus  to  the  anterior 
abdominal  until  it  becomes  fixed  there. 

Under  the  first  of  these  methods,  we  have  to  notice  an  operation  by  von  Rabenau.  In 
cases  where  a  pessary  cannot  be  borne  or  where  it  will  not  keep  the  uterus  to  the  front, 
he  amputates  the  anterior  lip  high  up,  and  says  that  the  resulting  contraction  causes  the 
uterus  gradually  to  become  anteflexed.  Six  cases  treated  thus  are  reported  on, "  but  they 
were  not  observed  over  a  long  enough  period  to  pronounce  on  the  ultimate  result. 

The  second  method  is  known  in  this  country  as  the  Alexander-Adams  operation.  It 
will  be  described  under  Prolapsus  Uteri,  as  it  is  used  for  the  treatment  of  prolapse  as 
well  as  retro  version. 

The  third  method  has  been  tried  by  various  operators — Koeberle  (1877),  Olshausen 
(1879),  Lawson  Tait  and  Heywood  Smith  (1880),  and  Kelly  (1885).  After  Olshausen1  called 
attention  specially  to  the  operation  by  reporting  on  two  cases,  we  find  Klotz4  recording 
seventeen,  Sanger5  seven,  Lee6  six,  and  Leopold7  nine.  Different  methods  of  attaching 
the  uterus  to  the  abdominal  wall  have  been  tried :  fixing  one  or  both  pedicles  (after 
removal  of  the  uterine  appendages)  into  the  abdominal  incision ;  stitching  the  round 
ligaments  to  the  abdominal  wall ;  or  Leopold's  method  (probably  the  best)  of  carrying 
three  of  the  sutures,  used  to  close  the  abdominal  incision,  also  through  the  upper  anterior 
aspect  of  the  fundus  (the  surface  of  the  fundus  to  be  apposed  to  the  wall  was  scraped  so 
as  to  ensure  better  adhesion,  but  Leopold  is  not  sure  that  this  is  necessary).  The  cases  in 

1  On  the  various  modes  of  treatment  of  the  worst  cases  of  uterine  flexions  :  Brit.  Gyn.  Trans.  1SSS, 
p.  229. 

2  Ueber  eine  neue  operative  Behandlung  der  Retroflexio  Uteri :  Centralb.  f.  Gyn.  1886,  p.  429. 

3  Ueber  ventrale  Operation  bei  Prolapsus  and  Retroversio  Uteri :  Centralb.  f.  Gyn.  1886,  p.  698. 
«  Centralb.  f.  Gyn.  1888,  S.  11. 

6  Ueber  operative  Behandlung  der  Retroversio-flexio  Uteri :.  Centralb.  f.  Gyn.  1888,  S.  17. 

8  The  value  of  Hysterectomy  in  the  Treatment  of  Retroflexions  of  the   Womb :  Americ.   Journ 
Obttet.  1888,  p.  1249. 

7  Saminlung  klinitcher  Vortriige,  No.  333. 


RETROFLEXION.  383 

which  this  operation  has  been  done  are  (1)  when  the  appendages  are  being  removed  at  any 
rate,  and  the  uterus  is  found  retroflexed  ;  (2)  when  ovarian  or  fibroid  tumours  which  have 
produced  permanent  retroflexion  are  being  removed  ;  (3)  when  there  is  retroflexion  alone, 
causing  serious  symptoms  and  incurable  otherwise  through  adhesions.  The  greatest 
difficulty  is  in  the  separation  of  adhesions — especially  when  they  are  tough  and  numerous 
and  implicate  the  bladder  and  ureters  or  rectum.  The  results  in  Leopold's  cases  as  to 
rel:.ef  of  symptoms  were  satisfactory,  but  it  is  evident  that  the  scope  for  such  an  opera- 
tion must  be  very  restricted. 

Apart  from  stitching  the  uterus  to  the  wall,  some  have  tried,  after  they  have  done 
laparatomy  for  releasing  the  retroflexed  uterus  from  adhesions,  to  keep  it  to  the  front 
by  means  of  the  glass  drainage  tube  passed  into  the  pouch  of  Douglas  and  the  consequent 
adhesions  set  up  along  the  tract  of  the  tube.  Polk  records  four  cases  in  which  he  did 
this  ;  and  Klotz  used  the  tube  in  addition  to  fixing  the  pedicles  of  the  uterine  appendages 
in  the  abdominal  incision.  Another  method  of  producing  adhesions  anterior  to  the  uterus 
has  been  tried  by  Schiicking, 2  who  passes  a  curved  guarded  needle  into  the  uterine  cavity 
like  a  sound ;  the  point  is  then  extruded  so  as  to  go  through  the  anterior  wall,  the 
utero-vesical  peritoneum  and  the  anterior  fornix  of  the  vagina.  The  thread  carried 
through  is  knotted  and  left  for  ten  to  fourteen  days,  and  by  its  irritation  sets  up  adhesions 
in  the  utero-vesicle  pouch.  In  eleven  out  of  twelve  cases  of  retroflexion  treated  thus, 
a  permanent  anteflexion  was  produced. 

1  Laparotomy  for  Adherent  Retroflexed  or  Ketroverted  Uterus :  Americ.  Journ.  Obstet.  1887,  p. 
630. 

-  Die  vaginale  Ligature  des  Uterus  und  ihre  Anwendung  bei  Retroflexio  und  Prolapsus  uteri : 
Centralb.f.  Gyn.  18S8,  S.  682. 


CHAPTER    XXXIV. 

INVERSION  OF  UTERUS. 

LITERATURE. 

Atthill — Inversion  of  uterus  due  to  fibroid  tumour  :  Dublin  Medical  Journal,  Feb.  1879. 
Aveling — On  Inversion  of  the  Uterus  :  Brit.  Med.  Journ.  1886,  I.,  p.  475.  Barnes — 
Diseases  of  Women :  London  1878,  p.  721.  Med.  Chir.  Trans,  1869.  Crosse—An 
Essay,  literary  and  practical,  on  Inversio  Uteri :  Trans.  Provincial  Med.  and  Sur. 
Assoc.,  London  1845.  Duncan,  Matthews — On  the  Production  of  inverted  Uterus  : 
Edin.  Med.  Jour.,  May  1867.  Emmet — Principles  and  Practice  of  Gynaecology  : 
Churchill,  London,  1884,  p.  406.  f'ritsch — Die  Lageveranderungen  der  Gebar- 
mutter  :  Billroth's  Handbuch  fiir  Frauenkrankheiten  :  Stuttgart  1881.  M'Clin- 
tock — Diseases  of  Women  :  Dublin  1863,  p.  76.  Macdonald — Two  cases  of  chronic 
inversion  of  the  uterus :  Edin.  Obst.  Trans.  Vol.  VI.,  p.  170.  Spiegelberg — Zu  den 
Inversionen  der  Gebarmutter  :  Archiv  f.  Gyn.,  B.  IV.  S.  350,  and  B.  V.  S.  118. 
Thomas — Diseases  of  Women,  p.  453,  Philadelphia  1880.  Werth — Ueber  partielle 
Inversion  des  Uterus  durch  Geschwiilste  :  Archiv  f.  Gyn.,  Bd.  XXII.  S.  65.  See 
also  Index  of  Recent  Gynecological  Literature  in  the  Appendix.  The  essay  by 
Crosse  gives  the  fullest  anatomical  description  of  inversion,  and  contains  a  series  of 
lithographic  plates  of  specimens. 

PATHOLOGY. 

IN  inversion  the  uterus  is  turned  inside  out,  so  as  to  form  a  polypoidal 
projection  into  the  vagina ;  its  peritoneal  surface  is  converted  into  a 
cup-shaped  hollow ;  its  mucous  membrane  becomes  everted  so  as  to  lie 
exposed  on  all  sides  in  the  cervix  and  vagina. 

The  mechanism  by  which  this  condition  is  brought  about  is  the 
following. 

1.  A  portion  of  the  muscular  wall  of  the  uterus  Jiaving  lost  its  tone, 
becomes  depressed  towards  the  uterine  cavity.     In  the  puerperal  condi- 
tion this  is  usually  that  portion  of  the  wall  to  which  the  placenta  has 
been  attached,  and  the  condition  has  been  described  by  Rokitansky  as 
"  paralysis  of  the  placental  seat;"  this  partial  inversion  will  be  frequently 
found  on  abdominal  palpation  in   cases   of  post-partum  haemorrhage 
(Fritsch).     In  cases  of  tumour-growth,  fatty  degeneration  (Scanzoni)  or 
malignant  infiltration  (A.  R.  Simpson)  weakens  the  wall  of  the  uterus 
round  the  base  of  the  polypoidal  growth,  and  thus  produces  an  analogous 
condition. 

2.  Muscular  contractions  of  the  non-depressed  portion  of  the  uterus, 
combined  with  intra-abdominal  pressure,   carry  the  depressed  portion 
further   into   the   uterine   cavity,   until    the    fund  us    reaches    the    os 


INVERSION. 


385 


internum  (fig.  234).  In  the  puerperal  condition,  muscular  contrac- 
tions occur  spontaneously,  or  are  produced  by  the  presence  of  the 
placenta ;  in  the  case  of  a  polypoidal  tumour,  they  are  due  to  the  pre- 
sence of  the  foreign  body.  Traction  from  beloio,  such  as  the  pulling 
away  of  the  placenta  or  the  tension  of  the  pedicle  of  a  polypus  which 
is  being  extruded,  also  produces  inversion. 

3.  The  fundus  of  the  uterus,  by  continuation  of  the  same  process, 
dilates  the  cervical  canal  and  is  "born"  into  the  vagina  (fig.  231). 

In  some  cases  inversion  seems  to  take  place  from  below  upwards  with 
a  mechanism  similar  to  that  of  prolapsus  uteri,  the  lower  part  of  the  body 
of  the  uterus  becomes  inverted  into  the  cervical  canal  (Taylor). 

Matthews  Duncan,  whose  paper  was  a  valuable  contribution  towards  Varieties 
establishing  the  correct  theory  of  inversion,  distinguishes  between  active  gionnver' 
and  passive  inversion.     The  active  is  that  described  above ;  the  passive 
is  produced  by  inertia  of  the  whole  uterus,  in  which  the  organ  is  driven 


FIG.  226. 

INVERSION  OF  UTERUS  (half-size,  Barnes  from  Crosse's  essay).  The  fundus  lies  in  the  vagina  ;  the 
cervix  is  not  inverted  ;  the  lips  are  flattened  out  to  a  swelling  seen  below  the  angle  of  inversion. 
The  ovaries  (seen  from  behind)  are  not  in  the  peritoneal  cup. 

down  entirely  by  intra-abdominal  pressure  or  by  traction  from  below — 
and  not  by  uterine  contractions. 

It  is  evident  that  the  process  may  become  arrested  at  any  of  these 
stages  and  persist  as  a  permanent  condition.  When  it  has  persisted 
for  a  few  weeks,  it  constitutes  "chronic  inversion;"  this  is  found  in  the 
following  forms.  (1.)  Inversion  of  one  horn  only  is  a  rare  occurrence. 
Slight  inversion  of  the  uterine  wall,  at  the  base  of  a  polypoidal  fibroid, 
has  been  more  frequently  observed.  (2.)  Partial  inversion,  when  the 
fundus  has  descended  as  far  as  the  os  internum,  is  also  found  as  a  chronic 
condition.  (3.)  Complete  inversion  is  the  condition  most  frequently 
met  with. 

An  exact  knowledge  of  the  relation  of  parts  in  complete  inversion  is  Anatomy 
necessary  for  diagnosis  and  treatment.     This  can  only  be  gained  by°ionnv( 
2s 


386 


AFFECTIONS  OF  UTERUS. 


studying  the  inverted  uterus  as  seen  in  section  (fig.  226).     We  must 
study  the  position  of — 

The  body  of  the  uterus, 

The  cervix  uteri, 

The  Fallopian  tubes  and  ovaries, 

The  peritoneum, 

The  bladder. 


V 


SmF.. 


u 


FIG.  227. 

INVERSION  OF  UTERUS+INVERSION  OF  VAGINA,  occasioned  by  a  small  sub-mucous  fibroid 
(Afl  Clintock).     Sm  F,  sub-mucous  fibroid  ;  U  uterus,  V  vagina,  B  bladder. 

The  body  of  the  uterus.  The  inversion  extends,  in  simple  uncompli- 
cated cases,  as  far  as  the  os  internum  but  no  further.  The  uterus 
lies  partly  in  the  vagina,  partly  in  the  cervical  canal.  Its  neck  is 
embraced  by  the  os  externum,  which  may  lie  loosely  on  it  (favouring 
haemorrhage)  or  constrict  it  firmly  (favouring  gangrene).  After  involu- 
tion takes  place,  it  becomes  small,  rounded  and  of  [firm  consistence, 


INVERSION.  387 

closely  resembling  a  pediculated  fibroid  tumour ;  and  it  has  been 
amputated  by  mistake  for  such.  It  has  a  rounded  form,  is  of  a  softer 
consistence  and  deeper  red  colour  than  a  pediculated  fibroid,  and  has  a 
smooth  and  slippery  surface  which  bleeds  freely  when  handled.  The 
softness  may  be  so  marked  that  the  uterus  moulds  itself  to  the  vaginal 
cavity  and,  becoming  flattened  against  the  posterior  vaginal  wall,  takes 
on  a  mushroom-like  form  (FreuncE). 

The  mucous  membrane  of  the  uterus  may  undergo  all  the  changes  of 
any  tumour  with  a  constricted  base  and  exposed  surface.  It  is  usually 
congested  and  bleeds  easily ;  it  may  become  ulcerated  and  even  gan- 
grenous, or  may  be  hypertrophied  with  polypoidal  formations ;  it  may 
lose  its  single  layer  of  cubical  epithelium  and  develop  a  stratified 
squamous  epithelium.  The  occurrence  of  these  changes  has  an  impor- 
tant bearing  on  the  necessity  of  replacing  the  organ. 

The  cervix  uteri.  This  is  rarely1  displaced  in  simple  uncomplicated 
inversion ;  it  forms  a  broad  ring  embracing  the  neck  of  the  tumour. 
Sometimes  the  inversion  is  complicated  with  prolapsus,  or,  more  pro- 
perly, the  vagina  also  becomes  inverted  and  the  inverted  uterus  caps 
the  inverted  vagina  (fig.  227).  When  this  occurs,  the  cervix  uteri  is 
also  more  or  less  inverted ;  a  part  remains  just  above  the  os  externum, 
as  a  depressed  ring  which  also  disappears  on  making  traction  on  the 
uterus  (Fritscli). 

The  Fallopian  tubes  and  ovaries,  with  some  coils  of  small  intestine, 
may  (at  first)  lie  within  the  inverted  cup,  which  is  lined  with  peri- 
toneum; afterwards,  they  retract  out  of  it.  In  long-standing  cases,  the 
rim  of  the  peritoneal  cup  is  contracted  by  the  muscular  fibre  of  the 
cervix  so  as  scarcely  to  admit  a  finger  (fig.  228).  In  a  case  of  six 
months'  standing,  in  which  A.  R.  Simpson  performed  Thomas'  operation 
before  having  recourse  to  amputation,  the  contracted  ring  just  admitted 
the  finger ;  an  ovary  was  caught  within  it. 

Adhesions  rarely  form  between  the  peritoneal  mrfaces ;  this  is  an 
interesting  fact  and  is  of  importance  in  regard  to  replacement.  We 
might  have  expected  detachment  of  the  peritoneal  lining  or  tearing  of 
it  by  the  sudden  dislocation;  the  previous  stretching  of  it  during 
pregnancy  is  perhaps  the  reason  why  this  has  not  been  noticed.  Fritsch 
says  that  the  lifting  up  of  the  fornices  by  the  tumour  in  the  vagina, 
diminishes  the  strain  on  the  peritoneum. 

The  bladder,  from  its  relation  to  the  cervix  (v.  Chap.  IV.),  is  not 
altered  in  position  unless  there  is  prolapsus.  When  the  latter  occurs, 
there  is  cystocele  (v.  fig.  227).  We  may  therefore  contrast  the  two 
types  of  inversion  as  follows. 

Inversion  of  uterus — cervix  and  bladder  normal  in  position. 

1  Crosse  figures  one  preparation  in  which  the  cervix  as  well  as  the  body  of  the  uterus  was  inverted 
although  there  was  no  prolapsus. 


388 


AFFECTIONS   OF  UTERUS. 


Inversion   of  uterus  +  prolapsus  (i.e.,  inversion  of  vagina) — cervix 
inverted  and  cystocele. 

ETIOLOGY   AND    FREQUENCY. 

Inversion  arises  under  two  different  conditions  : — 

1.  In  the  puerperium — puerperal  inversion ; 

2.  Secondary  to  intra-uterine  tumours  growing  from  the  fundus. 
Inversion  has  also  occurred  independent  of  the  puerperal  condition 

and  of  tumour  growth ;  this  is  quite  exceptional. 

Etiology  of      l.  Puerperal  inversion.     This  is  by  fat  the  most  frequent  form ;  out 
Inversion,  of  400  cases,  350  occurred  in  the  puerperal  uterus  (Crosse). 


FIG.  228. 

INVERSION  OF  UTERUS  (Crosse).  The  inverted  uterus  (U)  lying  in  the  vagina  (V)  is  cut  open  to  show 
the  peritoneal  sac  which  does  not  contain  the  ovaries  (0) ;  bristles  are  passed  into  uterine  orifices 
of  tubes,  b  Broad  and  r  round  ligaments ;  T  tube. 

Its  former  frequency  was  due  to  improper  management  of  the  third 
stage  of  labour.  When  the  uterus  was  flabby  and  not  contracting  and 
the  placenta  not  coming  away,  the  removal  of  the  latter  by  traction  on 
the  cord  drew  down  the  part  of  the  wall  to  which  it  was  attached  and 
thus  inverted  the  uterus.  This  accident  was  favoured  by  the  situation 
of  the  placenta  over  the  fundus  (He/twig).  Since  the  removal  of  the 
placenta  by  compression  (which  is  best  done  by  the  Crede  method — with 
the  thumbs  of  both  hands  well  down  behind  the  fundus  so  that  the 


INVERSION.  389 

uterus  may  be  firmly  compressed  antero-posteriorly)  has  been  adopted, 
this  accident  has  become  rarer. 

A  dilated  condition  of  the  uterus  (distention  by  blood  clots)  or  a 
flaccid  condition  of  the  walls  favours  inversion. 

2.  Inversion  secondary  to  uterine  tumours  is  much  rarer.     Of  400  cases,  Etiology  of 
only  forty  (ten  per  cent.)    arose  in  this  way  (Crosse).     It  has  been  d° g6^1011 
observed  with  pediculated  fibromata  (fig.  227), 1  and  will  be  referred  toTumours- 
again   when   we   treat   of  them   (v.   Chap.  XXXVIIL).     Brewis2   has 
recorded  a  case  of  its  occurring  spontaneously  in  a  uterus  from  which  a 
polypus  had  been  previously  discharged.     It  is  frequent  in  sarcoma 
(v.  Chap.  XLIIL),  but  very  rare  in  carcinoma  uteri.     Tait3  found  it 
with  villous  epithelioma,  and  Barnes  describes  a  specimen  in  which  both 
conditions  were  present,  but  does  not  say  which  was  the  primary  lesion. 

SYMPTOMS. 

The  symptoms  produced  by  inversion  at  the  time  of  its  occurrence, 
concern  the  obstetrician  rather  than  the  gynecologist.  There  is  the 
feeling  of  something  giving  way  in  the  pelvis,  accompanied  with  pain, 
haemorrhage,  and  sometimes  collapse.  With  complete  inversion,  there 
is  retention  of  urine  ;  it  often  occurs,  or  at  least  becomes  so  marked  as 
to  attract  the  patient's  notice,  when  she  has  made  a  straining  effort. 
The  cases  where  the  patient  says  that  it  first  came  down  several  days 
after  labour,  are  to  be  explained  by  supposing  that  partial  inversion 
occurred  after  labour  but  only  the  final  stage  attracted  attention. 

If  the  uterus  be  not  replaced  at  the  time,  the  case  becomes  one  of 
chronic  inversion.  The  symptoms  of  chronic  inversion  are — 

Haemorrhage, 

Pain  in  the  pelvis  of  a  bearing-down  character, 

Anaemia  and  weakness. 

Hcemorrhage  is  the  most  dangerous  symptom.  The  menstruation  is 
always  profuse,  as  may  be  easily  understood  from  the  fact  that  the 
mucous  membrane  is  extended  in  its  area  and  lies  exposed  in  the 
cervical  canal  and  vagina.  There  are  also  inter-menstrual  haemorrhage, 
which  comes  on  unprovoked  or  on  straining. 

The  bearing-down  pain  in  the  pelvis  resembles  that  felt  in  prolapsus 
uteri.  It  varies  indefinitely  in  intensity ;  sometimes  it  is  very  acute, 
rarely  is  it  so  slight  that  the  patient  becomes  reconciled  to  her  dis- 
comfort and  is  able  for  work. 

The  ancemia  and  weakness  may  be  so  marked  as  to  cause  suspicion  of 
malignant  disease. 

1  Lee  records  two  cases  of  its  occurrence  with  fibroid  tumours — Amer.  Journ.  Obstet.  1888,  p.  616. 

2  Edin.  Mai.  Journ.  July,  1887. 

3  Brit.  Med.  Journ.  188",  I.  p.  66. 


390 


AFFECTIONS  OF   UTERUS. 


DIAGNOSIS. 

Diagnosis  The  diagnosis  of  recent  inversion  is  easy.  If  the  placenta  has  not  yet 
Inversion,  been  born,  the  hands  laid  on  the  fundus  to  expel  it  by  the  Crede 
method  find  that  the  rounded  fundus  is  replaced  by  a  cup-shaped  hollow. 
The  cervix  is  sometimes  lifted  up  by  the  inverted  uterus,  so  as  to  be 
"  high  above  the  pubes,  even  near  the  umbilicus  "  (Crosse).  On  passing 
the  hand  into  the  vagina  to  remove  the  placenta,  care  is  required  to 
recognise  what  is  placenta  and  what  is  inverted  uterus,  and  not  to 
increase  the  inversion  in  detaching  the  placenta.  If  the  placenta  is 
already  expelled,  the  hand  on  the  abdomen  recognises  the  same  condi- 


FIG.  229. 

INVERTED  UTERUS  DRAWN  DOWN  BY  TAPE-NOOSE  ;  «  c  6  line  of  incision  in  cervix  in  Barnes' 
operation  (Barnes). 


tion ;  while  a  large  soft  body,  varying  in  size  according  to  the  extent  of 
the  inversion,  fills  the  vagina. 

Diagnosis  Chronic  Inversion.  Before  the  Sound  and  the  Bimanual  came  to  the 
Aversion.0  gynecologist's  aid  in  diagnosis,  it  was  impossible  to  diagnose  this  condi- 
tion with  certainty.  Mistakes  were  committed  by  the  most  eminent 
surgeons,  just  because  they  had  not  the  means  of  examination  which  we 
now  possess.  Even  nowadays  mistakes  occur  through  the  hasty 
making  of  a  diagnosis  before  all  the  means  of  examination  have  been 
employed.  We  therefore  describe  fully  the  routine  examination. 


INVERSION. 


391 


1.  Pass  the  fingers  into  the  vagina;  a  rounded  and  firm  or  flattened 
and  soft  tumour,  which  bleeds   easily,  is  felt  in  the  vaginal  cavity. 
Sweep  the  fingers  round  it,  and  recognise  that  it  is  free  on  all  sides 
except  at  its  iipper  extremity.     Round  this  extremity  is  felt  the  cervix, 
the  lips  and  fornices  being  recognised ;  or  the  cervix  is  thinned  out  to  a 
ring  and  the  fornices  obliterated.     If  the  cervical  canal  be  obliterated  by 
adhesions,  the  finger  will  not  pass  farther  up ;  if  it  be  patulous,  it  will 
pass  for  one-and-a-half  to  two  inches  and  find  that  the  cervical  mucous 
membrane  is  reflected  equally  all  round  on  to  the  neck  of  the  tumour. 

2.  With  one  finger  in  front  of  the  tumour  and  the  other  behind  it, 
lift  it  up  towards   the  abdominal  wall  which  is  depressed  with  the 
external  hand  till  the  fingers  in  the  vagina  are  in  contact  with  it.     The 


FIG.  230. 

UTERINE  POLYPUS  (after 
Thomas).  The  uterus 
in  its  normal  position. 
Sound  passes  into 
uterine  cavity. 


FIG.  231. 

INVERSION  OF  UTERUS  (after 
Thomas).  A  cup-shaped  de- 
pression is  in  the  place  of 
the  uterus.  Sound  arrested 
at  angle  of  flexion. 


FIG.  232. 

UTERINE  POLYPUS.    Adhesions 
round  pedicle  obliterate 
cervical  canal. 


external  hand  feels,  in  the  place  of  the  fundus  uteri,  a  truncated  body 
with  a  depression  in  the  centre  (see  fig.  231). 

3.  Now  pass  one  finger  into  the  rectum,  which  first  comes  on  the 
body  in  the  vagina :  drag  this  body  downwards  with  the  noose  repre- 
sented at  fig.  229,  as  the  volsella  causes  haemorrhage ;  the  finger  in  the 
rectum,  reaching  the  upper  border  of  the  body,  can  thus  feel  that  it 
ends  abruptly  and  can  pass  into  the  cup-shaped  end.     Now  depress  the 
abdominal  walls  till  they  reach  the  finger  in  the  rectum,  or  pass  a  sound 
into  the  bladder  and  direct  the  point  of  it  backwards  till  it  can  be 
touched  by  the  rectal  finger. 

4.  The  sound  may  be  used  to  probe  round  the  neck  of  the  body  where 


392 


AFFECTIONS  OF  UTERUS. 


there  is  not  space  for  the  finger  to  pass  upwards.     It  is  most  useful, 
however,  in  differential  diagnosis. 
Differential     DIFFERENTIAL  DIAGNOSIS.     Inversion  must  be  differentiated  from  the 

Diagnosis      „  ,,       .  ..  . 

following  conditions : — 

1.  Polypus  in  the  vagina,  simple  or  with  adherent  pedicle; 

2.  Intra-uterine  polypus ; 

3.  Uterine  polypus  with  partial  inversion  ; 

4.  Prolapsus  uteri ; 

5.  Inversion  and  prolapsus. 

1.  In  a  uterine  polypus  which  lies  in  the  vagina,  the  fundus  will  be 
found  to  lie  somewhere  else  than  in  the  vagina ;  it  may  be  retroverted 
and  thus  escape  recognition  in  the  Bimanual ;  the  rectal  examination 
will  then  discover  it.  Having  found  what  we  suppose  to  be  the  fundus, 
pass  the  sound  along  the  side  of  the  pedicle  ;  if  it  is  in  the  uterus,  the 


FIG.  233. 

POLYPUS  STILL  INTRA-UTERINE  (after  Thomas'). 


FIG.  234. 
PARTIAL  INVERSION  OF  UTERUS  (after  Thomas). 


sound  passes  more  than  1\  inches ;  if  it  passes  2~  inches  or  less,  suspect 
that  partial  inversion  complicates  the  polypus. 

When  there  are  adhesions  round  the  pedicle  obliterating  the  cervical 
canal,  a  careful  Bimanual  will  reveal  the  fundus  in  its  normal  position 
and  justify  us  in  breaking  down  the  adhesions  with  the  sound  so  as  to 
effect  a  passage  into  the  uterine  canal  (fig.  232). 

2.  In  a  uterine  polypus  which  is   still  intra-uterine  the  differential 
diagnosis  is  more  difficult.     A  case  has  been  recorded  in  which  inversion 
of  one  horn  of  the  uterus  was  diagnosed  and  amputated  as  a  polypus. 
A  careful  examination  per  rectum  under  chloroform  might  detect  the 
cup-shaped  depression  found  in  partial  inversion ;  the  uterine  cavity  is 
always  enlarged  when  a  polypus  is  present  (fig.  233  and  fig.  234). 

3.  Having  satisfied  ourselves  that  there  is  a  polypus,  the  possibility 
of  there  being  partial  inversion  of  the  uterus  at  its  attachment  must  be 


INVERSION.  393 

kept  in  view  (fig.  235).  A  careful  rectal  examination  might  reveal  a 
depression  on  the  peritoneal  aspect  of  the  uterus.  The  greater  sensitive- 
ness of  the  uterine  mucous  membrane  also  helps  us ;  thus  if  we  apply 
the  ecraseur  without  chloroform — which  is  not  necessary — to  remove 
the  polypus  and  the  patient  has  great  pain  on  our  tightening  up  the 
wire,  we  may  suspect  that  the  loop  has  embraced  the  wall  of  the 
uterus.  * 

4.  Uncomplicated  prolapsus  uteri  would  only  on  a  very  superficial 
examination  be  mistaken  for  inversion.  The  obliteration  of  the  fornices, 
the  presence  of  the  os  externum  at  the  end  of  the  protruded  tumour, 
and  that  of  the  uterus  within  it — as  demonstrated  by  the  sound  and 
examination  per  rectum — show  that  it  is  a  case  of  prolapsus.  If,  how- 
ever, the  prolapsus  be  due  to  a  fibroid  tumour  of  the  cervix  and  the  os 
externum  be  closed  by  adhesions  or  distorted,  diagnosis  is  more  difficult 
(v.  Uterine  Polypi). 


FIG.  235. 

UTERINE  POLYPUS  +  PARTIAL  INVERSION. 

5.  Prolapsus  +  inversion  is  a  rare  condition.  The  specimen  repre- 
sented at  fig.  227  is  quite  unique ;  the  apex  of  the  tumour  protruding 
through  the  vulva  consists  of  a  submucous  fibroid,  the  inverted  uterus 
constitutes  the  next  portion,  while  the  base  is  formed  by  the  inverted 
vagina. 

COURSE   AND    RESULTS    OF    CHRONIC    INVERSION. 

Spontaneous  reinversion  and  cure  has  been  observed,   according   to  Spontane- 
Thomas,  in  twelve  cases. 2     From  the  rarity  of  its  occurrence,  it  is  to  be  version"1 

1  Faucon  noted  this  in  one  case  even  though  the  patient  was  under  an  anaesthetic ;  the  inversion 
was  partial  and  only  of  one  horn,  and  could  not  be  recognised  before  the  operation — Sur  une  form 
particuliere  d'Inversion  polypeuse  de  1'uterus,  etc. — Archiv.  de  Toe.,  1887,  p.  1042. 

=  A  recent  case  is  recorded  by  Kemarski-Cen«?-aZ6./.  Gyn.,  1889,  S.  287. 


394  AFFECTIONS  OF   UTERUS. 

regarded  as  a  gynecological  curiosity  rather  than  a  natural  termination  ; 
the  mechanism  of  its  production  is  not  yet  known. 

Toleration  of  the  condition  is  also  rare,  though  cases  are  reported  in 
which  the  uterus  has  become  reconciled  to  its  new  position  and  sur- 
roundings and  the  patient  has  recovered  perfect  health. 

The  greater  proportion  of  unrelieved  cases  end  fatally  through 
anaemia,  haemorrhage,  septicaemia,  or  peritonitis. 

PROGNOSIS. 

As  to  the  hope  of  reduction — of  sixty-six  cases  collected  by  Mac- 
donald,  forty-four  were  successful. 

TREATMENT. 

Historical.  The  reposition  of  the  inverted  uterus  is  one  of  the  gynecological 
triumphs  of  the  last  five  and  twenty  years.  Up  to  1856  when  Tyler 
Smith  effected  reposition  by  gradual  compression  with  an  air  pessary, 
the  only  hope  of  cure  was  by  amputation  with  the  many  risks  attendant 
on  that  operation.  About  the  same  time  White  of  Buffalo  (1858) 
independently  succeeded  in  replacing  an  inversion  by  pressure  with  the 
hand.  After  these  a  number  of  successful  cases  are  recorded,  among 
which  the  most  noteworthy  is  one  of  Noeggerath  who  replaced  an  inver- 
sion of  thirteen  years'  duration. 

Various  methods  of  reduction  have  been  recommended  by  Tyler 
Smith,  White,  Emmet,  Courty,  Noeggerath,  Thomas,  Matthews  Duncan, 
Barnes,  Braxton  Hicks,  and  Tate.  It  would  take  too  much  space  to 
describe  each  method  in  detail ;  the  references  will  enable  the  student 
to  consult  the  original  articles. 

The  treatment  of  inversion  is  best  considered  as  follows  : — 

A.  Reposition  (a)  with  the  hand  alone  or  aided  by  instruments, 

(V)  by  continuous  slight  elastic  pressure ; 

B.  Amputation. 

A.  Reposition. 

The  obstacle  to  reposition  is  the  resistance  of  the  tissue  of  the  lower 
segment  of  the  uterus ;  the  principle  of  treatment  is  to  overcome  this 
by  steady  pressure. 

Suppose  that  we  have  a  case  of  inversion,  how  are  we  to  proceed  ? 
The  patient  is  kept  perfectly  at  rest  for  a  few  days ;  injections  of  very 
warm  water  are  employed  twice  or  thrice  daily ;  nutritious  diet  is  given, 
and  iron  is  usually  required  for  anaemia.  Ergot  is  required  if  there  is 
menorrhagia ;  should  it  not  be  the  menstrual  period,  the  best  thing  to 
check  haemorrhage  is  injection  of  very  hot  water. 

Having  thus  prepared  the  patient  we  proceed  to  reposition.  Are  we 
to  employ  the  more  rapid  manual  method  or  the  slower  one  with  an 


INVERSION.  395 

instrument  ?  If  the  patient  does  not  object  to  an  operation  under  chloro- 
form and  if  we  can  have  assistants  to  take  turns  with  us  in  keeping  up 
manual  pressure,  the  former  method  should  certainly  be  tried  first. 

(a.)  deposition  ivith  the  hand  alone  or  aided  by  instruments.  For  a  Reposition 
few  days  previously,  the  largest  size  Barnes  bag  which  the  patient  can 
bear  is  placed  in  the  vagina  and  distended ;  this  makes  space  for  the 
operator's  hand,  and  may  itself  effect  the  reposition. 1  The  patient,  under 
chloroform,  is  placed  in  the  lithotomy  position  ;  pass  the  right  hand  into 
the  vagina,  and  grasp  the  uterus  with  the  fingers  as  far  into  the  angle  of 
reflexion  as  possible  (fig.  236).  Now  press  the  uterus  steadily  upwards 


FIG.  236. 

REPOSITION  OF  THE  INVERTED  UTERUS  WITH  THE  HAND  ALONE  (after  Emmet). 

against  the  left  hand  on  the  abdomen.     The  fingers  maybe  separated  as 
far  as  possible  so  as  to  open  out  the  cervix.2 

Sometimes  the  process  of  re-inversion  is  started  by  dimpling  inwards  Noegger- 
one  horn  of  the  uterus,  and  then  forcing  the  depressed  horn  onwards  asra 
a  wedge  to  open  up  the  ring  of  the  cervix.3     As  the  hand  cannot  keep  White, 
up  steady  pressure  for  any  length  of  time,  a  cup  is  set  on  a  curved  iron 
rod  with  a  spiral  spring4  to  make  the  pressure  equal.     A  curved  wooden  Atthill. 

1  Kroner  has  collected  six  cases  of  inversion  (longest  of  eleven  years  standing)  replaced  by  this 
means ;  the  pressure  was  applied  for  periods  varying  from   one  to  eleven  days. — Archiv  f.  Gyn., 
B.  xiv.,  S.  270. 

2  Emmet — Op.  cit.  p.  418.     It  is  very  doubtful  whether  the  constricting  cervix  has  anything  to  do 
with  preventing  reposition,  though  upward  and  outward  pressure  round  the  neck  favours  it. 

3  Noeggerath— Am.  Med.  Times,  18(52,  vol.  iv.  pp.  230,  235. 

1  White— Intern.  Med.  Cong.  Trans.,  Philadelphia,  1876.     Byrne — New  York  Med.  Journ.,  Oct. 
187S. 


396 


AFFECTIONS  OF  UTERUS. 


rod,  with  a  large  cup  at  one  end  and  a  small  one  at  the  other,  has  also 

been  used  to  keep  up  pressure. x     The  end  of  the  instrument  is  pressed 

against  the  operator's  chest,  and  the  cup  is  steadied  with  the  hand  in  the 

vagina.     It  is  evident  that  these  instruments  require  a  roomier  vagina 

than  when  the  hand  alone  is  used ;  and  if  the  cup  slips  unexpectedly  it 

may  rupture  the  fornix.     Counter-pressure  is  made  over  the  abdomen 

with  the  hand,  or  if  the  abdominal  walls  are  thin  and  there  is  a  distinct 

Thomas,     cup  on  the  peritoneal  aspect,  with  a  cone  of  wood, 2  which  is  used  to  dis- 

Schroeder.  tend  the  ring  of  the  cervix ;  the  traction  can  be  taken  off  the  vaginal 

walls  by  fixing  the  cervix  with  volsellse. 3     Counter-pressure  may  be  made 

Courty.      per  rectum  in  the  following  way  : — Pass  index  and  middle  fingers  of  right 

hand  into  rectum,  draw  down  the  uterus  with  the  left  hand  or  the  noose 


Tate. 


FIG.  237. 

WHITE'S  REPOSITOR,  WITH  ELASTIC  SPRING  PLACED  AGAINST  THE  OPERATOR'S  CHEST.  While  the 
right  steadies  cup  and  uterus,  counter-pressure  is  made  with  the  left  hand  or  better  by  an 
assistant  (Thomas). 

(fig.  229)  until  these  fingers  get  fairly  above  the  cervix  so  as  to  press  on 
the  margins  of  the  peritoneal  depression ;  grasp  uterus  now  with  left 
hand,  turning  it  so  that  the  fundus  is  towards  the  symphysis  and  the 
cervix  towards  the  sacrum ;  finally,  make  pressure  with  the  index  and 
thumb  in  the  angle  of  reflexion  against  the  two  fingers  in  the  rectum. 4 
The  urethra  has  also  been  dilated  so  as  to  allow  one  finger  to  press  on 
the  anterior  rim  of  the  depression,  while  the  rectal  finger  presses  on  the 
posterior.5  To  weaken  the  resistance  of  the  cervix,  lateral  incisions 
have  been  made  into  its  substance  (Barnes,  see  fig.  229). 

1  Atthill— Loc.  cit.    Braxton  Hicks— Brit.  Med.  Journ.,  Aug.  1872. 

2  Thomas—  Op.  cit.  p.  408.  3  Schroeder—  Op.  cit.,  S.  203.     Atthill— Inc.  cit. 

*  Courty—  Maladies  de  I'uterus,  1866.  6  Tate—  Cincinnati  Lancet  and  Observer,  March  1871. 


INVERSION.  397 

This  manual  pressure  is,  with  the  help  of  assistants,  to  be  kept  up 


.FIG.  238. 

TATE'S  METHOD  OF  MAKING  COUNTER-PRESSURE  WITH  FINGERS  IN  BLADDER  AND  RECTUM  (Mundi) 


FIG.  239. 

EMMET'S  METHOD  OF  RETAINING  THE  PARTIALLY  RE-INVERTKD  FUNDUS  BY  CLOSING  THE  os  EXTERNUM 
WITH  SUTURES  ;  the  traction,  produced  in  the  direction  of  the  arrows,  favours  re-inversion 
(Emriiet). 

from  half-aii-hour  to  two  hours  according  to  the  condition  of  the  patient. 


398  AFFECTIONS   OF   UTERUS. 

If  not  successful  in  this  time,  the  patient  is  kept  in  bed  and  under  the 
influence  of  opium  while  a  Barnes  bag  is  placed  in  the  vagina  to  main- 
tain the  uterus  as  far  as  it  has  been  replaced.  When  the  uterus  has 
Emmet,  been  so  far  reinverted  that  the  fundus  is  above  the  level  of  the  os 
externum,  the  lips  of  the  latter  may  be  drawn  together  with  wire 
sutures  (fig.  239). 1 

Abdominal  Abdominal  section,  so  as  to  allow  the  operator  to  get  at  the  con- 
fOT^nver-  Dieting  rim  of  the  cup  from  its  peritoneal  side  and  dilate  it  with  ex- 
sion.  panding  forceps,  has  been  proposed  by  Thomas.  It  was  successful  in  the 

first  case ;  a  second  proved  fatal  from  peritonitis.  It  has  been  tried  un- 
successfully by  A.  R.  Simpson,  while  Malins, "  and  more  recently  Munde,3 
succeeded  so  far  in  dilating  the  ring,  but  failed  in  pulling  up  the  uterus 
by  the  ingenious  method  of  passing  a  thread  through  the  fundus  ; 
Schmalfuss  4  has  recently  recorded  a  successful  case.  Brown5  suc- 
ceeded in  dilating  the  ring  by  getting  at  it  per  vaginam  through  an 
incision  in  the  inverted  fundus ;  a  dilator  was  introduced  and  the  rim 
expanded  :  the  incision  in  the  uterus  was  stitched  before  the  inverted 
fundus  was  pushed  up. 

Reposition  (&)  Reposition  by  continuous  slight  elastic  pressure.  If  manual  repo- 
by  Elastic  gj^jon  has  failed,  we  try  the  more  gradual  method ;  in  some  cases  we 
employ  it  from  the  first.  Gradual  pressure  may  be  produced  by  an 
india-rubber  bag  placed  in  the  vagina  and  distended  Avith  water  from  a 
douche-can  so  that  hydrostatic  pressure  is  brought  to  bear. fi  Thiry 7  has 
devised  an  ingenious  bag  consisting  of  a  double-walled  india-rubber  cap- 
sule, which  is  slipped  over  the  uterus ;  when  distended  with  air,  it  com- 
presses and  pushes  up  the  inverted  fundus.  Pressure  by  an  inflated  bag 
is  not  so  efficient  as  that  produced  by  a  wooden  cup  set  on  a  stem8  with  a 
vaginal  (or,  better  still,  a  vaginal  and  permeal) 9  curve  so  that  the  pressure 
is  made  in  the  axis  of  the  brim.  Pressure  may  also  be  made  by  the  four 
elastic  bands  which  pass,  two  in  front  and  two  behind,  to  a  broad 
abdominal  bandage ;  by  the  tightening  of  the  front  or  the  back  bands, 
the  direction  of  pressure  is  altered. 

In  this  method  there  are  two  points  which  require  careful  attention. 
(1.)  The  elastic  pressure  must  always  act  in  the  line  of  the  axis  of  the 
inverted  uterus,  and  likewise  of  the  axis  of  the  pelvic  brim ;  the  cup 
is  apt  to  slip  off  the  uterus,  and  the  handle  of  the  instrument  to  alter 
its  direction.  Pressure  in  a  wrong  direction  is  injurious,  and  may  produce 
sloughing.  To  prevent  these  accidents  we  pad,  with  wadding  soaked  in 

Emmet— Op.  cit.,  p.  430.  *  Lancet,  1885,  II.,  401. 

Amer.  Journ.  Obstet.  1888,  p.  1279.  *  Centralb.  f.  Gyn.  1886,  p.  745. 

New  York  Med.  Journ.,  Nov.  24,  1883. 

Range — Lancet,  1887,  I.,  p.  1293.  Jaggard  records  an  interesting  case  of  inversion  of  twenty-one 
months'  standing  reduced  after  thirty- three  days'  use  of  the  colpeurynter — Amer.  Journ.  OMet. 
18  7,  p.  130. 

Archiv.  de  Tocolog.,  1885,  p.  925.  8  Lawson  Tait—  Obst.  Journ.  vol.  iv.,  p.  555. 

Aveling — Loc.  cit.,  records  ten  cases  of  successful  reposition  with  his  cup  and  stem  which  has  a 
sigmoid  curve. 


INVERSION.  399 

carbolised  oil,  all  round  the  neck  of  the  inverted  uterus  and  round  the 
cup  of  the  repositor  when  in  situ  ;  we  watch  the  position  of  the  instru- 
ment, and  remove  and  re-apply  it  every  day  so  as  to  see  how  it  is  press- 
ing and  whether  there  is  sloughing. 

(2.)  There  must  be  effective  counter-pressure,  so  as  to  take  the  strain 
off  the  vaginal  walls.  This  is  effected  by  means  of  a  broad  flannel 
bandage,  firmly  secured  round  the  loins,  under  which  cotton  wool  is 
padded  in  such  a  way  as  to  press  exactly  upon  the  fundus. 

The  elastic  pressure  is  kept  up  from  one  to  three  weeks.  Cases  of 
reposition  at  this  period,  or  even  after  it,  are  recorded.1 


FIG.  240. 

CUP  WITH  STEM  AND  ELASTIC  BANDS  which  are  fixed  to  an  abdominal  belt,  for  gradual  reduction  of 

inversion  (Thomas). 

In  cases  of  inversion  due  to  tumour  growth,  the  tumour — if  simple — 
must  be  removed  in  the  first  instance ;  we  then  wait  to  see  if  the  uterus 
will  replace  itself,  and  if  it  does  not  we  proceed  to  replace  it.  If  the 
tumour  be  malignant,  the  propriety  of  amputating  the  uterus  with  the 
tumour  must  be  considered. 

£.  Amputation. 

Amputation  of  the  inverted  uterus  is  justifiable  (except  in  cases  of 
malignant  disease)  only  after  all  means  of  reposition  have  been  fairly 

1  As  by  Neugebauer,  after  three  weeks—  Centralb.f.  Gyn.  1887,  p.  63. 


400 


AFFECTIONS  OF   UTERUS. 


Amputa- 
tion of 
Inverted 
Uterus 
with  the 
knife. 


tried  and  failed,  or  when  the  uterus  is  extensively  ulcerated  and  gan- 
grenous. The  length  of  duration  of  the  inversion  is  no  argument  for 
amputation ;  Noeggerath  replaced  one  of  thirteen  years'  standing. 

The  morality  in  amputation  is  high,  1  in  3  (Crosse).  The  dangers  of 
the  operation  are — 

Haemorrhage, 

Septicaemia, 

Peritonitis, 

Retraction  of  the  stump  into  the  peritoneal  cavity. 

We  describe  the  operation  as  we  have  seen  A.  R.  Simpson  perform  it 
with  success. 

The  following  are  the  instruments  required : — 

Vaginal  douche,  Bistouries, 

Elastic  ligature,  Scissors, 

Sims'  speculum,  Long  straight  fixed  needles, 

Spatulae,  Smaller  curved  needles  and  holder, 

Volsellse,  Silver  wire — two  thicknesses, 

Dissecting  and  artery  forceps,  Carbolised  silk  and  catgut. 

Place  the  patient  in  the  lithotomy  posture,  under  chloroform.  Keep 
up  irrigation  with  the  douche  during  the  whole  operation.  Hook  back 
the  labia  with  spatulas,  to  be  held  by  the  assistants  who  steady  the 
legs ;  draw  down  the  perineum  with  Sims'  speculum,  to  be  held  by 
another  assistant. 

Ascertain  before  making  any  traction  on  the  uterus  where  the  natural 
neck  of  the  inverted  portion  lies,  and  pass  round  it  an  elastic  ligature 
knotted  so  as  to  control  haemorrhage.  The  natural  neck  is  our  guide  as 
to  the  line  of  amputation ;  if  we  drag  more  of  the  uterus  down  into  the 
constricting  loop,  the  stump  is  liable  to  spring  back  after  the  amputation 
has  been  performed. 

Pass  three  or  four  wire  sutures  through  the  uterus  in  an  antero- 
posterior  direction,  about  an  inch  below  the  constricting  ring,  as 
described  under  the  operation  for  amputation  of  the  cervix  (v.  p.  284) ;  the 
same  figures  will  show  how  the  sutures  are  passed  in  this  operation,  if 
we  suppose  the  inner  circle  (which  represents  the  mucous  membrane  of 
the  cervical  canal  in  fig.  169)  to  represent  the  cross  section  of  the  peri- 
toneal pouch.  The  advantages  of  passing  these  sutures  before  amputat- 
ing are  the  following :  they  are  ready  in  situ  to  control  haemorrhage ; 
they  give  us  a  purchase  on  the  stump  when  the  portion  in  the  bite  of 
the  forceps  is  cut  away ;  they  are  more  easily  passed  at  this  stage. 

The  uterus  is  now  amputated  about  half  an  inch  below  these  sutures. 
Bleeding  points  of  any  size  are  ligatured  with  catgut  on  the  end  of  the 
stump.  The  lips  are  then  brought  together  with  the  deep  sutures 
already  passed.  Kaltenbach  ties  the  lateral  sutures  over  the  sides  in- 


INVERSION.  401 

stead  of  the  end  of  the  stump ;  this  constricts  the  uterine  arteries  more 
efficiently.  More  superficial  ones  are  placed  between  these  to  bring 
the  mucous  membrane  together.  To  prevent  re-inversion  of  the  cervix, 
it  has  been  proposed  to  stitch  the  stump  to  the  adjoining  cervical 
mucous  membrane.  The  india-rubber  constrictor  is  now  notched  so  as 
to  diminish  its  pressure,  and  finally  cut  through.  The  ligatures  are 
left  long  enough  to  be  brought  out  at  the  vaginal  orifice,  and  a  drainage 
tube  is  placed  in  the  cervical  canal. 

The  elastic  ligature  is  preferred  by  a  great  many  operators ;  when 
used,  we  should  cut  away  as  much  of  the  tissue  below  the  ligature  as 
possible  to  minimise  the  risk  of  septicaemia  from  the  necrosed  tissue. 
To  keep  it  from  slipping,  Spencer  Wells  transfixed  the  uterus  with 
needles ;  Courty  x  makes  a  furrow  with  the  cautery  to  hold  the  ligature. 
Instead  of  putting  the  elastic  ligature  directly  on  the  neck  of  the 
tumour,  a  silk  noose  may  be  applied  on  a  stem  like  that  for  a  wire 
ecraseur  and  the  ends  tied  to  an  elastic  cord  so  as  to  give  elastic 
traction. 2 

Re-inversion  of  the  stump  is  a  serious  accident,  as  the  raw  surface  now  Re-inver- 
lies  in  the  peritoneal  cavity  and  may  be  a  source  of  septicaemia ;  further, 
it  is  beyond  our  control  should  haemorrhage  occur.  In  two  cases  of 
amputation  with  the  galvano  -  caustic  wire,  performed  by  Spiegel- 
berg,  3  this  accident  occurred :  in  these  no  bad  effect  followed,  because 
the  discharge  escaped  by  the  cervical  canal ;  he  attributes  this  happy 
result  to  the  fact  that  the  stump-surface  of  the  galvano-caustic  wire, 
being  a  convex  cone,  became,  on  re-inversion,  a  concave  cone  opening 
into  the  cervical  canal. 

1  Archiv.  de  Tocolog.,  1885,  p.  922.  *  Poncet :  Areliiv.  de  Toe.,  1886,  p.  351. 

3  Archiv  f.  Gyn.,  Bd.  IV.,  S.  358. 


2c 


CHAPTER  XXXV. 

TUMOURS  OF  THE  UTERUS.     FIBROID  TUMOURS : 
PATHOLOGY  AND  ETIOLOGY. 

LITERA  TORE. 

Barnes — Diseases  of  "Women,  p.  746  :  London,  1878.  Doran — On  Myoma  and  Fibro- 
myoma  of  the  Uterus  and  allied  Tumours  of  the  Ovary  :  Trans,  of  Lond.  Obs.  Soc., 
1888,  p.  410.  Duncan,  Matthews — Haemorrhage  from  Fibrous  Tumours  of  the 
Uterus  :  Edin.  Med.  Jour.,  Jan.  and  Feb.  1867.  Gusserow— Die  Neubildungen 
des  Uterus :  Deutsche  Chirurgie,  Stuttgart,  1885.  Johnston — A  Review  of  some 
collected  Cases  of  Fibromata  of  the  Cervix  Uteri :  Am.  Journ.  of  Obstet.,  Nov.  and 
Dec.  1885.  Kleinwachter— Zur  Entwickelung  der  Myome  des  Uterus  :  Zeitsch.  f. 
Geb.  und  Gyn.,  Bd.  IX.  S.  68.  Klob — Pathologische  Anatomic  der  weiblichen 
Sexualorgane,  S.  149 :  Wien,  1864.  Lee — Tumours  of  the  Uterus :  London,  1847. 
M'Clintock — Diseases  of  Women  :  Dublin,  1863.  Beamy — Case  of  Fibroid  Polypus 
of  the  Uterus,  with  remarks  on  some  points  in  Etiology  (with  Discussion) :  Amer. 
Jour.  Gyn.,  1886,  pp.  813  and  859.  Routh— Fibrous  Tumours  of  the  Womb  : 
London,  1864.  Schorler — Ueber  Fibromyome  des  Uterus  :  Zeitsch.  f.  Geb.  und  Gyn., 
Bd.  XI.  S.  139.  Schroeder— Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  218  : 
Leipzig,  1886.  Simpson,  Sir  J.  Y.— Diseases  of  Women,  p.  659:  Edin.  1872. 
Thomas— Diseases  of  Women,  p.  519 :  Philadelphia,  1880.  Winckcl — Ueber  Myome 
des  Uterus,  etc.  :  Volkmann's  Sammlung  klin.  Vortrage,  No.  98,  1876.  Wyder — 
Die  Mucosa  uteri  bei  Myomen  :  Arch.  f.  Gyn.,  Bd.  XXIX.  S.  1.  See  also  Index  of 
Recent  Gynecological  Literature  in  the  Appendix. 

Intro-  OP  tumours  of  the  uterus,  the  most  important  are  Fibroids  and  Cancer, 
tory>  less  important  Adenoma,  Sarcoma,  and  Papilloma ;  and  in  the  chapters 
that  follow  we  shall  have  to  consider  Fibroids  and  Cancer  at  some 
length,  the  others  briefly.  The  term  "polypus"  is  so  convenient  clini- 
cally that  we  retain  it,  but  we  must  remember  that  it  involves  cross- 
classification,  including  one  variety  of  fibroid  tumour — the  fibrous 
polypus — while  the  mucous  polypus  is  a  pediculated  adenoma.  Adenoma 
of  the  uterine  mucous  membrane  has  only  of  recent  years  been  receiving 
attention ;  we  shall  refer  to  it  under  carcinoma,  as  its  chief  importance 
is  in  connection  with  the  early  stages  of  that  affection. 

Fibroid  tumour  is  considered  first,  as  in  frequency  it  comes  before 
cancer,  although  in  seriousness  the  latter  is  by  far  the  more  important. 
It  presents  a  remarkable  contrast  with  cancer  in  every  respect :  it  shows 
itself  early  in  life,  while  cancer  is  late;  it  occurs  among  the  well-to-do, 
while  cancer  makes  its  ravages  among  the  poor  and  badly  fed;  it  is  the 
tumour  of  the  sterile,  while  cancer  is  that  of  the  parous;  it  very  rarely 
affects  life,  while  the  fate  of  the  cancer-patient  is  almost  sealed. 


FIBROID   TUMOURS:   PATHOLOGY.  403 

Synonyms. — Myoma  or  Fibro-myoma  Uteri ;  Fibrous  Tumour;  Tutneur 
fibreuse;  Hysterome. 

As   this   tumour   is   composed   of  both   the   connective  tissue   andNomen- 
muscular  elements  of  the  wall  of  the  uterus,  it  is  at  once  a  fibroma  and  clature> 
a  myoma ;   the  most  correct  term  is  therefore  fibro-myoma.     In  the 
majority  of  cases,  however,  the  fibrous  tissue  preponderates,  so  that  the 
tumour  resembles  a  fibroma ;  the  English  term  fibroid  (a  term  derived 
from  the  root  of  fibroma  and  eldos  =  like  a  fibrous  tumour)  is  therefore 
not  inappropriate,  and  is  also  more  convenient. 

PATHOLOGY. 

Under  this  head  we  shall  describe  their 
Situation ; 

Structure — naked  eye  and  microscopic  ; 
Mode  of  growth,  varieties  ; 
Changes  in  uterus ; 
Degenerative  changes. 

SITUATION. 

They  occur  much  more  frequently  in  the  body  of  the  uterus  than  in 
the  cervix ;  of  seventy-four  cases  of  fibroid  tumours  recorded  by  Lee, 
only  four  were  in  the  cervix.  In  the  body  of  the  uterus  the  most 
common  seat  is  the  posterior  wall;  they  occur  less  frequently  in  the 
anterior  wall,  and  very  rarely  at  the  sides  of  the  uterus.  The  soft,  truly 
muscular  form  is  most  commonly  situated  at  the  fundus. 

STRUCTURE. 

They  are  composed  of  the  same  elements  as  the  muscular  wall  of  the  Naked-eye 
uterus,  viz.,  of  non-striped  muscular  fibre  and  fibrous  tissue.     These  are  Of  a  Fibroid 
both  present  in  every  case,  as  the  name  for  these  tumours  (fibro-myoma)  Tumour- 
implies.      The  proportion  of  these  constituents,   however,   varies;   in 
some  rare  cases  the  muscular  tissue  preponderates,  producing  a  true 
myoma  which  is  not  circumscribed  and  grows  rapidly;    more  usually 
there  is  excess  of  fibrous  tissue  producing  a  fibro-myoma,  which  is  dis- 
tinctly marked  off  from  the  wall  of  the  uterus  and  grows  slowly.     The 
naked-eye  characters  of  the  myoma  are  those  of  a  pale,  flesh-coloured 
tumour  having  a  soft  consistence,  passing  gradually  into  the  surround- 
ing uterine  wall,  and  usually  single.     The  fibro-myoma,  by  far  the  most 
frequent  form, x  is  of  firm  consistence  which  makes  it  feel  like  a  foreign 
body  in  the  softer  muscular  wall;   it  is  of  a  pale  colour,  resembling 
fibrous  tissue ;  it  cuts  like  cartilage,  the  cut  surface  having  a  glistening 
satin-like  appearance  and  being  often  uneven  through  the  firmer  fibrous 

1  Doran  (loc.  cit.)  thinks  the  frequency  of  fibro-myoma  as  compared  with  myoma  is  over-estimated. 
Young  fibroids  are  "pure  myomata  with  or  without  connective  tissue." 


404 


AFFECTIONS  OF   UTERUS. 


tissue  forcing  out  the  softer  parts  between ;  the  bundles  of  fibrous  tissue 
have  a  concentric  arrangement  round  one  or  more  centres  (fig.  241). 
Capsule  of  The  tumour  is  surrounded  by  loose  fibrous  tissue,  which  with  the 
immediately  adjoining  muscular  layer  constitutes  the  so-called  capsule  ; 
it  has  a  broad  connection  at  one  point  with  the  muscular  tissues  of  the 
wall,  or  becoming  entirely  detached  from  it  lies  free  in  its  capsule.  This 
looseness  of  the  tissue  round  the  tumour  is  important  in  relation  to  its 
removal  by  the  process  described  as  enucleation.  Few  blood-vessels 
penetrate  into  the  substance  of  the  tumour,  although  the  tissue  im- 
mediately round  it  is  very  vascular  and  often  contains  enlarged  veins 
which  resemble  the  venous  sinuses  of  the  pregnant  uterus  (fig.  251) ; 


Micro- 


tion. 


FIG.  241. 

SECTION  OK  A  LARGE  FIBROID  TUMOUR,  with  the  Fibres  arranged  round  several  centres 
(Sir  /.  Y.  Simpson). 

nutrition  is  apparently  effected  by  transudation  from  the  capsule.  In 
some  rare  cases,  however,  these  tumours  possess  a  cavernous  structure 
consisting  of  dilated  blood-vessels.  Virchow  has  described  this  form  as 
"Myoma  teleangiectodes  seu  cavernosurn  ;  "  cases  are  recorded  by 
Leopold  and  Schroeder. 

On  microscopic  examination,  the  myomatous  form  has  the  appearance 
°^  muscular  fibre  of  the  uterus  —  the  muscle-cells  being,  according  to 
Doran,1  larger  than  those  of  the  uterus  in  which  it  grows.  The 

1  Loc.  cit.    He  figures  a  section  of  a  myoma  from  a  pregnant  uterus  which  shows  this  well,  the 
muscle-cells  being  still  larger  than  the  hypertrophied  ones  of  the  uterus. 


FIBROID   TUMOURS:    PATHOLOGY. 


405 


fibroniatous  form  (common  fibroid  tumour)  has  the  appearance  shown 
at  fig.  242,  in  which  the  wavy  bundles  of  fibrous  tissue  are  well  seen. 
Sometimes  the   bundles   of    fibrous    tissue    are   separated   by   spaces 
(fig.  243),  which  Klebs  considers  to  be  lymphatic  spaces.     Nerves  have  Lymphatic 
been  traced  into  the  substance  of  these  tumours  by  Lorey ;  but,  as  an  -Bundles- 
interesting  case  recorded  by  Freund  shows,  they  are  not  sensitive  : — 
a  submucous  fibroid  was  extruded  beyond  the  vulva;    the  lower  third, 
which  protruded  beyond   its  capsule  of  mucous  membrane,   was  not 


FIG.  242. 

SECTION  OF  FIBROID  TUMOUR,  showing  wavy  bundles  of  fibrous  tissue  }  (Gusserotc). 

sensitive  to  the  prick  of  a  needle ;  the  upper  two-thirds,  from  their 
being  still  covered  by  mucous  membrane,  were  very  sensitive.  The 
mucous  membrane  covering  them  is  ciliated,1  like  that  of  the  uterus 
generally ;  though  when  it  has  been  exposed  for  some  time  (e.g.  when 
a  fibrous  polypus  comes  to  be  in  the  vagina)  it  becomes  squamous. 2 


FIG.  243. 
SECTION  OK  FIBROID  TUMOUR,  showing  spaces  between  bundles  of  fibrous  tissue  \  (Giuserow'). 

MODE    OF   GROWTH,    VARIETIES. 

Fibroid  tumours  grow  slowly  ;  the  more  they  consist  of  fibrous  tissue,  Rate  of 
the  slower  the  growth.  During  pregnancy,  they  increase  more  rapidly 
in  size  ;  in  the  puerperium,  they  may  become  smaller  again  and  even 
cease  to  be  recognisable.  It  is  difficult  to  determine  the  rapidity  of 
growth.  It  is  unsatisfactory  to  estimate  it  from  the  appearance  of 
symptoms  and  compare  the  time  elapsed  with  the  present  size  of  the 


1  Gervis—  Brit.  Med.  Journ.,  1886,  II.,  p.  S71. 


2  Reamy—  Loc.  cit.,  p.  817. 


406 


AFFECTIONS  OF  UTERUS. 


Mode  of 


Varieties 


tumour  ;  the  only  reliable  data  are  got  from  the  examination  of  the 
tumour  from  time  to  time.  Schorler  has  reported  on  18  cases  observed 
by  Schroeder  and  comes  to  this  conclusion  :  A  tumour  will  not  grow  to 
be  for  the  first  time  recognisable  in  less  than  three  months'  time  and  in 
a  year  may  not  be  much  larger  ;  in  five  years  it  may  grow  to  the  size  of 
a  man's  fist,  and  in  thirteen  to  the  size  of  the  head.  It  is  evident  that 
these  statements  only  give  a  general  idea  of  the  rapidity  of  growth,  to 
which  there  are  great  exceptions. 

After  the  menopause,  their  growth  is,  as  a  rule,  arrested  ;  the  meno- 
pause is  generally  late  in  cases  of  Fibroids. 

All  fibroid  tumours  are,  in  the  beginning,  interstitial  or  intra-mural. 
As  they  increase  in  size  they  expand  in  the  substance  of  the  wall  or 
towards  one  of  the  free  surfaces  (peritoneal  or  mucous),  thus  becoming 
subperitoneal  or  submucous.  Hence  three  varieties  are  recognised  — 
interstitial,  subperitoneal,  and  submucous.  It  is  evident  that  these  terms 
are  revive,  as  &  i8  difficult  to  say  when  an  interstitial  fibroid  becomes 


FIG.  244. 

PEDICULATED  SUBPERITONEAL  FIBROID  TUMOUR  (Sir  J.  Y.  Simpson). 

submucous.  Gusserow  limits  the  term  "submucous"  to  pediculated 
submucous,  and  "  subperitoneal  "  to  pediculated  subperitoneal  fibroids. 
A  submucous  tumour,  however,  often  gives  rise  to  the  clinical  signs 
diagnostic  of  the  submucous  variety  long  before  it  becomes  pediculated. 
Each  variety  requires  short  description.  For  the  sake  of  convenience, 
we  describe  first  the  fibroid  tumours  found  in  the  body  of  the  uterus  ; 
the  comparatively  rare  fibroid  tumours  of  the  cervix  are  best  noticed 
separately  (p.  412). 

A.  The  Subperitoneal  grow  outwards  into  the  peritoneal  cavity.  The 
thickness  of  the  pedicle  varies  (compare  fig.  244  with  fig.  245)  ;  its 
length  determines  the  mobility  of  the  tumour.  When  the  tumour 
attains  a  certain  size,  one  of  two  things  happens.  (1.)  It  may  grow  up 
men.*  ^n*°  *ne  abdomen  and  expanding  there  draw  the  uterus  forcibly  upwards, 
producing  by  this  traction  elongation  of  the  cavity  (fig.  245)  with  thin- 


Subperi- 
Fibroids, 


Growth 


FIBROID   TUMOURS:    PATHOLOGY. 


407 


ning  of  the  walls.  An  interesting  case  is  recorded  by  Times1  in  which 
the  cavity  of  the  body  of  the  uterus  was  elongated  to  six  inches;  the 
cervical  canal,  extending  only  one  inch  inwards  from  the  os  externum, 
ended  blindly  at  a  point  two  inches  distant  from  the  beginning  of  the 
cavity  of  the  body ;  the  intervening  portion  was  obliterated  so  as  to 
form  a  solid  muscular  cord.  Virchow  says  that  the  body  may  even  be 
torn  from  the  cervix  by  forcible  traction.  (2.)  The  tumour,  growing  Incarcera- 
from  the  first  within  the  pelvis,  may  through  pressure  produce  t 


FIG.  245. 

UTERUS  WITH  ELONGATED  CAVITY  DUE  TO  THE  PRESENCE  OF  SEVERAL  FIBROID  TUMOURS 
(Sir  /.  Y.  Simpson). 

symptoms  of  incarceration ;  or,  having  a  long  pedicle,  may  fall  down 
from  the  abdomen  into  the  pelvis  and  produce  similar  symptoms.  The 
point  of  origin  of  the  tumour  and  the  length  of  the  pedicle  determine 
whether  these  symptoms  can  be  relieved  by  pushing  the  tumour  out  of 
the  pelvis.  Twisting  of  the  pedicle  occurs  less  frequently  in  fibroid  than 

1  Land.  Obit.  Tranit.,  vol.  ii.,  p.  34. 


408 


AFFECTIONS   OF   UTERUS. 


in  ovarian  tumours;  when  it  occurs,  it  leads  to  oedema  or  gangrene. 
schroeder1  mentions  a  case  where,  on  operating,  he  found  the  tumour 
distended  with  blood  from  partial  twisting  of  the  pedicle.  Gangrene  of 
the  tumour,  leading  to  a  fatal  peritonitis,  was  observed  by  Cappie ; 2 
the  pedicle  was  twisted  round  its  axis  one  and  a  half  times.  Adhesions 
form  with  other  organs,  as  occurs  with  all  abdominal  tumours ;  these 
may  become  new  sources  of  nutrition.  Sometimes  they  lead  to  detach- 
ment of  the  tumour  from  the  uterus  :  the  tumour  is  anchored,  as  it  were, 
to  the  abdominal  walls ;  and,  when  the  uterus  from  pregnancy  or  other 
causes  becomes  displaced,  the  pedicle  gives  way.  Turner3  reports  a 
case  in  which  a  small  calcareous  fibroid  was  found  free  in  the  pouch  of 
Douglas ;  a  second  was  attached  to  the  posterior  wall  of  the  bladder  and 


FIG.  246. 
INTERSTITIAL  FIBROID  TUMOUR  (Sir  J.  Y.  Simpson). 

to  the  pelvis ;  a  third  was  bound  down  to  the  bladder  and  the  pelvic 
wall  by  adhesions,  but  still  retained  its  connection  with  the  uterus  by 
a  thin  pedicle.  Adhesions  to  the  intestines  have  produced  symptoms  of 
intestinal  obstruction.4  Hernial  protrusion  of  the  abdominal  walls  has 
been  described  by  Dull :  5  he  reports  two  cases  of  this  very  rare 
occurrence ;  in  one  case,  the  skin  covering  the  hernial  sac  became 
gangrenous,  so  that  the  tumour  lay  exposed. 

1  Op.  cit.,  8.  230.  2  OMet.  Journ,  ii.,  p.  303.  x  Sdin.  Med.  Journ.,  1861,  p.  69S. 

4  Bade— Lancet,  Dec.  21,  1872. 

8  Cited  by  Schroeder,  op.  cit.,  S.  233.    Lawson  Tait  mentions  the  same  condition— Brit.  Med. 
Journ.,  1888,  I.,  p.  861. 


FIBROID   TUMOURS:    PATHOLOGY. 


409 


E.  The  Interstitial  remain  in  the  substance  of  the  uterine  wall,  and  Interstitial 
do  not  become  pediculated.     The  appearance  of  such  a  tumour  is  well  * 
seen  at  fig.  246.     Usually  there  are  many  such  tumours  present  (fig. 
245) ;  Schultze  counted  as  many  as  fifty  in  one  uterus,  and  Thomas 
describes  the  uterus  of  a  negress  containing  thirty-five. 

C.  The  Submucous  are  the  most  important  clinically.  They  lie  im- Submucous 
mediately  underneath  the  uterine  mucous  membrane,  and  project  into  the 
cavity  of  the  uterus  (fig.  247).  They  are  attached  along  a  broad  base,  or 
by  a  pedicle  ;  when  they  hang  free,  they  are  known  as  fibrous  polypi — 
the  most  frequent  form  of  uterine  polypi  (v.  Chap.  XXXIX.).  When  a 
fibroid  tumour  projects  into  the  uterine  cavity,  it  acts  as  a  foreign  body 
and  produces  uterine  contractions.  These  lead,  in  some  instances,  to 
pedunculation  of  the  tumour  and  even  to  its  extrusion  from  the  uterine 


Fibroids. 


FIG.  247. 
SCBMUCOUS  FIBROID  TUMOUR  PROJECTING  INTO  UTERINE  CAVITY  (Sir  J.  Y.  Simpson). 

cavity ;  in  such  a  case,  it  hangs  as  a  polypus  in  the  vagina.  In  other 
rare  cases,  the  capsule  ruptures  and  the  liberated  tumour  is  expelled  in 
shreds — spontaneous  enucleation. 

The  muscular  ivall  hypertrophies,  more  especially  when  the  tumour  Changes  in 
is  submucous  or  interstitial.  A  small  fibroid  lying  in  the  lower  segment 
of  the  uterus  has  caused  the  whole  organ  to  hypertrophy  to  the  size  of  a 
child's  head.  x  In  submucous  fibroids,  the  mucous  membrane  is  also  hyper- 
trophied.  According  to  Wyder, 2  the  increase  in  thickness  is  limited  to 
the  portion  over  the  tumour  and  is  due  to  a  hypertrophy  affecting  in 


Uterus. 


1  Tillaux—  Gaz.  des  Hop.,  1867,  Xo.  144. 


-  Archiv  f.  Gyn.,  Bd.  xiii.  S.  35. 


410 


AFFECTIONS  OF   UTERUS. 


some  cases  the  glands  and  in  others  the  connective  tissue.     The  mucous 
membrane  may  ulcerate  leading  to  enucleation  of  the  tumour. 

In  a  more  recent  paper1  he  gives  a  very  full  account  of  the 
changes  in  the  mucous  membrane  which  he  has  examined  carefully  in 
twenty  cases  of  uteri  removed  in  Gusserow's  Clinique  in  Berlin.  His 
object  was  to  study  it  specially  with  a  view  to  the  cause  of  menorrhagia 


FIG.  248. 
PEDICULATED  SCBMUCOUS  FIBROID  IN  PROCESS  OF  EXTRUSION  (Sir/.  Y.  Simpson). 

which  is  the  important  symptom  of  fibroids.  From  a  comparison  of  the 
mucous  membrane  in  subperitoneal  as  compared  with  interstitial  he 
comes  to  the  conclusion  that  the  thicker  the  muscular  capsule  is  the  less 
likely  is  the  tumour  to  affect  the  circulation  in  the  mucous  membrane.  The 

1  Loc.  eit.  S.  34,  38. 


FIBROID   TUMOURS:  PATHOLOGY.  411 

uterine  glands  in  this  case  are  hypertrophied,  but  the  interglandular  tissue 
little  or  not  at  all  affected ;  while  the  nearer  the  tumour  comes  to  the 
uterine  cavity,  the  more  does  the  interglandular  connective  tissue  become 
affected,  and  this  sometimes  at  the  expense  of  the  glands  which  atrophy. 
The  bearing  of  this  on  bleeding  is  that  it  is  the  affection  of  the  inter- 
glandular tissue,  causing  compression  of  the  veins,  which  leads  to  con- 
gestion and  bleeding. 

Changes  in  the  position  of  the  uterus  have  been  already  referred  to ; 
when  subperitoneal  fibroids  rise  up  into  the  abdomen,  it  is  sometimes 
drawn  forcibly  upwards  by  them  and  may  be  twisted  on  itself.1  At 
other  times  the  weight  of  a  subperitoneal  or  interstitial  tumour  leads  to 
prolapsus  iiteri.  Inversion  of  the  uterus  is  also  occasioned  by  submucous 
fibroids  when  these  are  situated  near  the  fundus  and  when  their  pedicle 
does  not  admit  of  their  extrusion  as  polypi.2 

DEGENERATIVE  CHANGES. 

These  are  the  following : — Softening,  Induration,  Calcification,  Sup- 
puration. 

The  softening  may  be  due  to  oedema,  to  fatty  degeneration,  or  to  Softening, 
myxomatous  degeneration.  The  occurrence  of  oedema  is  unquestioned, 
and  many  cases  of  sudden  increase  in  the  size  of  fibroid  tumours 
may  be  thus  explained.  From  analogy  with  the  changes  affecting 
muscular  fibre  in  the  puerperal  uterus,  we  should  expect  fatty  degene- 
ration to  occur ;  there  is,  however,  only  a  small  quantity  of  muscular 
tissue  present  in  these  tumours.  There  are  only  two  cases3  recorded  in 
which  the  existence  of  fatty  degeneration  has  been  demonstrated  by 
microscopic  examination,  although  many  cases  are  reported  in  which 
this  is  supposed  to  have  occurred.  Myxomatous  degeneration,  resulting 
in  the  formation  of  spaces  containing  mucus  between  the  layers  of  the 
tumour,  sometimes  occurs. 

Induration,  with  atrophy  or  shrinking  of  the  tumour,  occurs  in  someindura- 
cases  after  the  menopause ;  the  muscular  tissue  fattily  degenerates  and tlon> 
disappears,  the  fibrous  tissue  contracts.*     An  infarction  has  also  been 
found. 5 

When  calcification  occurs,  lime  salts  (chiefly  phosphates)  are  deposited  Calcifica- 
in  the   fibrous  tissue  and  produce  the   so-called  womb-stones.6     Thistlon< 
deposit  usually  commences  in  the  centre  of  the  tumour  and  extends  out- 
wards, more  rarely  in  the  external  layers  so  as  to  form  a  shell  round  the 

1  As  in  the  case  reported  by  Ktister— Beitrage  zurGeb.  u.  Gyn.  1872,  i.,  8.  7  ;  the  uterus  was  twisted 
two  and  a  half  times,  so  that  the  broad  ligaments  formed  a  spiral.     Skutsch  records  another  case 
operated  on  by  Schultze  in  which  the  uterus  was  twisted  half  round— Centralb.f.  Gyn.  1887,  S.  p.  52. 

2  Kotschau  records  a  case  of  partial  inversion,  with  what  he  calls  "  eversion  of  the  uterine  mucous 
membrane,"  i.e.  its  being  pushed  downwards  without  the  tumours  becoming  pediculated — Centralb. 
/.  Gyn.  1S87,  S.  757. 

3  Gusserow— Zoc.  cit.,  S.  32.     The  cases  are  reported  by  Freund  and  Martin. 

4  Sir  J.  Y.  Simpson— Obst.  Mem.,  p.  115. 

5  ^y  v-_Ott.     The  patient  had  felt  pain  over  it,  ascribed  to  a  local  peritonitis—  Centralb.  f.  Gyn. 
XII.  S.  2(4. 

6  See  a  recent  case  by  Bach— Amer.  Journ.  Obstet.  1886,  p.  293. 


412  AFFECTIONS   OF   UTERUS. 

tumour.  Sometimes  it  is  so  extensive  that  the  tumour  can  be  cut  with 
the  saw,  and  the  cut  surface  polished ;  more  usually  it  is  incomplete,  and 
forms  a  coral-like  skeleton.  Calcification  of  portions  of  the  tumour  is 
often  accompanied  with  suppuration  in  others,  probably  from  interference 
with  nutrition. 

Suppura-  Suppuration  occurs  frequently  in  submucous  fibroids,  as  the  result  of 
injury  from  operative  interference  or  from  constriction  of  the  pedicle 
during  the  process  of  expulsion.  It  has  also  been  observed  as  a  rare 
occurrence  in  subperitoneal  fibroids,  accompanying  calcification  or  from 
torsion  of  the  pedicle.  In  such  a  case,  the  tumour  either  finds  its  way 
through  the  abdominal  walls  or  fatal  peritonitis  follows. 

Carcino-  Whether  cardnomatous  degeneration  specially  affects  fibroid  ti\mours, 
Degenera-  is  a  disputed  point.  We  occasionally  find  carcinomatous  degeneration 
tion.  jn  a  uterus  where  a  fibroid  tumour  is  also  present  (fig.  280)  or  from 

which  a  polypus  has  on  a  former  occasion  been  removed.  Whether 
this  is  merely  a  coincidence,  or  whether  there  is  a  liability  that  the  non- 
malignant  tumour  may  become  the  seat  of  malignant  disease,  is  not 
settled.  The  practical  importance  of  this  question  is  evident. 

As  to  the  frequency  of  these  various  changes,  Martin1  gives  us  the 
following  interesting  statistics  of  his  own  cases.  Of  205  fibroids  he  found 
slight  retrogressive  changes  in  70,  fatty  degeneration  in  3,  suppuration 
in  10,  cedematous  swelling  in  11,  cystic  degeneration  in  8,  blood-cavities 
in  3,  sarcomatous  degeneration  in  6,  but  never  carcinoma. 

FIBROID  TUMOURS  OF  THE  CERVIX. 

The  occurrence  of  fibroid  tumours  in  the  cervix  is  rare ;  but,  when 
they  are  present,  they  often  give  rise  to  difficulty  in  diagnosis  on  account 
of  the  distortion  which  they  produce.  They  spring  from  either  wall,  and 
grow  outwards  towards  the  peritoneal  cavity  or  downwards  into  the 
cellular  tissue  beside  the  vagina.  When  subserous,  they  easily  produce 
symptoms  of  incarceration,  as,  from  their  low  position,  they  are  liable 
to  become  wedged  in  the  pelvis.  When  submucous,  they  produce  elon- 
gation of  one  lip  and  may  form  a  polypoidal  tumour  in  the  vagina 
(fig.  249) ;  the  accompanying  distortion  of  the  os  externum  leads  to 
difficulty  in  diagnosis.  Cases  in  which  a  large  tumour  bulges  through 
the  ostium  vaginae  have  been  mistaken  for  inversion  and  prolapsus. 
Sometimes  prolapsus  is  due  to  the  weight  of  the  tumour  and  disappears 
after  its  removal. 2  The  interstitial  form  is  easily  mistaken  for  inver- 
sion when  the  os  is  converted  into  a  transverse  cleft  which  escapes 
observation  and  the  unaffected  lip  is  thinned  out  to  a  mere  band. 

Johnston  reports  on  ninety-six  cases  of  fibroid  tumour  of  the  cervix, 
dealing  especially  with  their  effect  on  pregnancy  and  labour.  He  finds 

1  Ueber  Myome  :  Archivf.  Gyn.  Bd.  XXXII.  S.  470. 

2  Barnes—  Obst.  Tram.,  III.,  p.  211. 


FIBROID   TUMOURS:    ETIOLOGY. 


413 


that  abortion  is  more  frequent  with  fibroid  tumours  in  the  body,  pre- 
mature labour  with  those  in  the  cervix ;  he  affirms  that  during  preg- 
nancy or  labour  one-third  of  the  mothers  and  more  than  one-half  of  the 
children  die  so  that,  where  the  tumour  cannot  be  removed,  celibacy  is 
to  be  recommended. 

ETIOLOGY. 

Gusserow,  to  whose  exhaustive  article — Die  Neubildungen  des  Uterus 
— in  Billroth's  Handbuch  we  are  greatly  indebted  in  this  Chapter,  says 
in  regard  to  etiology,  "  Ueber  die  Ursachen  der  Uterusmyome  wissen  wir 
so  wenig,  wie  iiber  die  Ursachen  der  meisten  pathologischen  Neubild- 
ungen, namlich  Nichts"  (of  the  causes  of  fibroid  tumours  we  know  as 
little  as  of  the  causes  of  most  pathological  new-formations,  that  is 
nothing).  Virchow  and  Winckel  have  both  made  elaborate  attempts  to 


FIG.  249. 

CERVICAL  FIBROUS  POLYPUS  springing  by  a  pedicle  from  the  region  of  the  os  internum,  and  pushing 
itself  under  the  whole  mucous  membrane  of  the  cervical  canal ;  so  that  its  insertion  is  partly 
continuous  with  the  tissue  of  the  uterus,  partly  truly  submucous.  Between  these  a  cavity  has 
formed  through  tearing  of  the  mucous  membrane,  so  that  the  tumour  has  apparently  two 
pedicles  (Schroeder). 

assign  a  cause  to  the  development  of  fibroid  tumours.  The  number  and 
variety  of  causes  adduced  by  these  observers  only  show  how  far  we  are 
from  the  knowledge  of  the  real  cause  ;  with  such  a  variety  of  causes,  the 
difficulty  would  not  be  to  explain  why  they  are  present  in  some  but  why 
they  are  not  present  in  every  case.  The  development  of  the  true 
myoma  has  been  recently  studied  by  Kleinwachter.  He  examined  uteri 
with  very  small  myomata  and  found  that  there  was  a  small  isthmus  of 
muscular  fibre  uniting  the  myomatous  mass,  lying  in  its  connective 
tissue  capsule,  with  the  muscular  tissue  around.  This  isthmus  some- 


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FIBROID   TUMOURS:    ETIOLOGY.  415 

times  bifurcates  and  resembles  in  form  an  obliterated  blood-vessel 
(capillary).  He  also  saw  some  capillaries  surrounded  with  round  cells 
and  forms  transitional  to  muscular  fibres.  Hence  he  concludes  that  the 
true  myoma  is  due  to  a  degeneration  of  a  blood-vessel  with  its  branches. 
From  finding  micrococci  in  them,  Galippe  and  Landouzy1  have  suggested 
that  they  are  due  to  the  irritation  of  a  parasite. 

Olshausen2  has  found  pain  (sensitiveness  to  pressure  and  dysmenor- 
rhoea)  and  menorrhagia  complained  of  before  any  tumour  could  be 
detected  by  palpation,  and  thinks  this  points  to  congestion  of  the 
uterus  as  being  an  early  clinical  symptom  in  some  cases  of  myoma. 

Fibroids  are  without  doubt  the  most  frequent  new-formation  in  the 
uterus.  Klob  says  that  they  are  present  in  50  p.c  of  women  who  die 
over  fifty  years  of  age  ;  and  Bayle,  in  20  p.c.  of  those  who  die  over  thirty- 
five  years ;  both  of  these  estimates  are  probably  beyond  the  mark. 

Their  appearing  is  in  some  way  related  to  the  development  of  theDevelop- 
sexual  apparatus.     Thus,  there  are  no  well-authenticated  cases  of  their  p-tnt-^ 
arising  before  puberty3  or  after  the  menopause.     The  majority  of  patients  according 
are  between  the  ages  of  thirty  and  forty  when  they  first  seek  medical  °  age' 
advice,  as  it  is  evident  from  the  accompanying  table  based  on  statistics 
collected  by  Gusserow  (fig.  250).     Schroeder  says  that  of  196  patients, 
who  during  three  years  of  his  private  practice  consulted  him  for  fibroid 
tumours,  104  were  between  forty  and  fifty,  and  62  between  thirty  and 
forty. 

Sexual  activity  predisposes  to  their  development,  as  they  are  more 
frequent  in  married  than  in  unmarried  women.  Of  1876  cases  from 
various  authorities  collected  by  Reamy,4  we  find  that  1422  or  75o/°  of 
persons  with  fibroid  tumours  seeking  advice  were  married  ;  the  larger 
number  of  married  compared  with  unmarried  persons  must  be  borne  in 
mind  in  judging  of  such  figures.  It  is  important  to  note  this  as  it  was 
formerly  supposed  that  single  life  favoured  their  development.  As  the 
presence  of  a  fibroid  tumour  interferes  with  conception,  we  often  find 
sterility  present. 

1  Brit.  Med.  Journ.  1887,  I.  p.  799. 

2  Notizen  ueber  das  klinische  Anfangsstadium  der  Myome  :  Archivf.  Gyncik.  XXVIII.  S.  494. 

3  Tillaux  reports  a  case  of  a  fibroid  tumour  of  the  cervix  in  a  girl  of  nineteen  which  had  caused 
symptoms  for  six  years. — Annales  de  Gyn.  XXVI.,  p.  241. 

*  JLoc.  cit.  p.  818. 


CHAPTER    XXXVI. 

FIBROID  TUMOURS  OF  THE  UTERUS:   SYMPTOMS; 
DIAGNOSIS;  PROGNOSIS. 

LITERATURE. 
See  Literature  of  Chaps.  XXXV.  and  XXXVII. 

LIKE  other  pathological  conditions  of  the  uterus,  fibroid  tumours  some- 
times produce  no  symptoms  and  their  presence  is  discovered  accidentally 
or  on  post-mortem  examination.  This  absence  of  symptoms  is  more  likely 
to  occur  should  the  tumour  be  small,  or  should  there  be  no  sexual 
activity  as  in  unmarried  women.  In  the  latter  case,  although  symptoms 
appear  only  when  the  patient  enters  married  life,  the  tumour  may  have 
been  already  a  long  time  present.  Subperitoneal  tumours,  even  when 
large,  may  only  produce  discomfort  from  undue  abdominal  distention. 
The  symptoms  usually  present  may  be  tabulated  as  follows  : — 

1.  Menorrhagia,  irregular  haemorrhages ; 

2.  Painful  menstruation ; 

3.  Pelvic  sensations  due  to  size  and  weight  of  tumour,  peritonitic 

pain; 

4.  Symptoms  of  pressure  on  bladder  and  rectum, 

blood-vessels  and  nerves, 
ureters ; 

5.  Sterility  and  abortion. 

Hsemor-  1.  Haemorrhage  is  the  most  characteristic  symptom  in  submucous 
Fbge'dQ  fibroids,  and  appears  first  as  a  gradual  increase  of  the  normal  menstrual 
flow ;  it  never  begins  with  a  sudden  flooding  as  in  carcinoma  uteri.  In 
menorrhagia,  the  haemorrhage  comes  from  the  hypertrophied  mucous 
membrane  of  the  uterine  cavity  generally ;  it  does  not  come  from  the 
mucous  membrane  covering  the  surface  of  the  tumour  which  is  frequently 
thinned  and  atrophied,  nor  from  the  substance  of  the  tumour  itself 
which  as  we  have  seen  is  sparingly  vascular.  When,  however,  the  sub- 
mucous  fibroid  projects  as  a  polypus,  passive  congestion  and  haemorrhage 
from  the  mucous  membrane  covering  it  may  be  occasioned  by  the  con- 
striction of  its  pedicle.  Irregular  haemorrhages  arise  from  ulceration  of 
the  mucous  membrane  covering  the  tumour,  or  rupture  of  the  dilated 


SYMPTOMS  OF  FIBROID   TUMOURS. 


417 


veins  in  its  capsule.  Fig.  251  shows  a  case 1  in  which,  through  the  rupture 
of  a  uterine  sinus  in  the  lower  part  of  the  tumour,  a  sudden  and  fatal 
haemorrhage  occurred.  In  subperitoneal  fibroids  menstruation  is  not 
increased,  and  in  certain  rare  cases  is  diminished. 

2.  Pain  accompanies  menstruation.     In  the  submucous  variety  there  Pain  in 
is  often  characteristic  uterine  dysmenorrhoea,  in  which  the  pain  resembles  Fibroids- 


FIG.  251. 

UTERUS  CONTAINING  FIBROID  TUMOUR,  from  a  case  which  terminated  fatally  through  haemorrhage. 
Note  the  large  venous  sinuses  in  the  capsule,  one  of  which  ruptured  at  the  point  a  {Matthews 
Dv/iicati). 

labour  pains.  The  congestion  causes  the  polypus  to  swell  and  this  pro- 
duces uterine  contractions  (v.  Uterine  Polypi).  In  interstitial  and  even 
in  subserous  fibroids,  there  is  often  pain  at  the  menstrual  period  which 

1  Reported  by  Matthews  Duncan— Edin.  Med.  Jour.,  1867,  p.  634.     He  also  refers  to  a  case  of 
Cruveilhier's  in  which  death  was  occasioned  in  the  same  way. 
2D 


418  AFFECTIONS  OF   UTERUS. 

cannot  be  thus  explained.  In  subserous  fibroids  with  a  pedicle  con- 
taining large  vessels,  as  well  as  in  interstitial,  Gusserow  ascribes  the 
pain  to  the  distention  of  the  tumour  with  blood.  This  pain  is  of  a 
stretching  or  dragging  nature,  and  is  quite  different  from  the  pain  of 
uterine  contractions. 

Weight  3.  Increased  weight  of  the  uterus  occasions  sensations  of  discomfort, 

in  Fibroids,  which  are  described  as  "fulness  or  weight  in  the  pelvis,"  "  a  sensation 
of  dragging,"  "bearing-down  pain."  When  the  tumour  is  so  large  that 
it  fills  the  pelvis  and  becomes  wedged  in  it,  intense  pain  is  produced ; 
this  is  either  always  present,  or  recurs  only  at  the  menstrual  periods 
when  the  tumour  is  distended  by  blood.  As  in  carcinoma  uteri, 
peritonitic  pains — indicated  by  local  tenderness  and  reflex  contraction  of 
abdominal  muscles — may  arise  at  any  time  from  secondaiy  chronic 
peritonitis.  Neuralgic  pain  is  sometimes  present  locally  (see  below), 
but  may  be  also  through  the  whole  body. 

Pressure  4.  Frequency  of  micturition,  due  to  pressure  on  the  bladder,  is  the 
inFibroids.  m°st  common  pressure  symptom.  Pressure  on  the  urethra  produces 
difficulty  of  micturition  and  even  retention ;  with  some  patients,  this 
recurs  regularly  at  the  menstrual  period.  Even  very  small  fibroids, 
when  they  are  situated  in  the  anterior  uterine  wall,  may  press  on  the  neck 
of  the  bladder  and  produce  symptoms  of  cystitis.  Pressure  on  the  rectum 
by  fibroids  in  the  posterior  wall  occasions  constipation  or,  more  rarely, 
mucous  diarrhoea.  Incarcerated  fibroids  have  produced  complete  obstruc- 
tion, and  led  to  a  fatal  result 1  or  furnished  an  indication  for  colotomy. 
Intestinal  obstruction  has  also  resulted  from  adhesions  between  the 
tumour  and  the  small  intestine. 2  Pressure  on  the  veins  produces  haemor- 
rhoids and  varicose  veins  in  the  legs.  Interesting  cases  of  neuralgia 
due  to  pressure  on  pelvic  nerves  have  been  recorded.  In  these  cases  the 
neuralgia  entirely  disappeared  as  soon  as  the  tumour  was  lifted  up  and 
supported  by  a  pessary.3  Compression  of  the  ureters,  with  consequent 
dilatation  and  hydronephrosis,  occurs  less  frequently  in  fibroid  tumours 
than  in  carcinoma.  The  reason  for  this  is  evident ;  in  carcinoma  the 
compression  is  due  to  infiltration  of  the  tissue  round  the  ureter,  which 
from  the  anatomical  relation  of  the  ureters  to  the  cervix  easily  occurs ; 
fibroid  tumours  in  their  growth  simply  press  against  the  ureters,  and 
may  push  them  aside.  Several  cases  of  single  and  double  hydrone- 
phrosis and  of  death  from  uraemia4  have  been  recorded.  Bright's 
disease  has  developed  secondarily.5  In  fibroid  tumours  where  pressure 
symptoms  are  present,  we  should  always  examine  the  urine. 

Sterility          5.  Sterility  is  frequent.     Of  149  cases  of  married  women  collected  by 
8' Schroeder,  33  per  cent,  were  sterile  and  the  average  number  of  children 

1  Holdhouse — Land.  Path.  Soc.  Trans.,  III.  371.  2  Bade— Lancet,  Dec.  21,  1872. 

»  Kidd— Dub.  Quart.  Journ.,  1872.    Jude  Hue— Annales  de  Gyn.,  IV.,  p.  239. 

4  Gusserow  quotes  cases  from  Jude  Hue,  Murphy,  Hanot — Neubildunyen,  etc.,  S.  52. 

*  Hubert— Bui.  de  la  Soc.  Anatom.,  1873,  p.  870. 


SYMPTOMS   OF  FIBROID   TUMOURS.  419 

to  each  mother  was  about  three.  When  conception  occurs,  fibroid 
tumour  may  lead  to  abortion  or  complicate  labour. 

PROGRESS   AND    RESULTS. 

A  relative  cure  usually  takes  place  at  the  menopause,  when  the  tumour 
ceases  to  grow.  In  the  case  of  subserous  tumours,  this  may  happen 
even  before  that  time. 

Spontaneous  disappearance  of  the  tumour  has  been  observed  in  certain  Spontane- 

cases,  although  nothing  definite  is  known  as  to  the  means  by  which  it  isous  c^s" 

0  »  appearance 

effected.     After  sifting  the  reported  cases,  Gusserow's  conclusion  is  that  of  Fibroids. 

there  are  thirty  cases  in  which  this  undoubtedly  occurred. x  Out  of  these 
thirty,  thirteen  were  associated  with  the  puerperium  and  the  rest  chiefly 
with  the  menopause.  We  might  account  for  their  disappearance  during 
the  puerperium  by  a  process  analogous  to  invohition.  Of  the  reason  of 
the  disappearance  at  the  menopause  we  know  nothing. 

Complete  cure  also  results  from  spontaneous  expulsion.     This  occurs  in  Spontane- 
three  ways:-  -^f^ 

(1.)  By  pediculation  and  extrusion  of  the  tumour  as  a  polypus  Fibroids. 

(v.  under  Uterine  Polypi) ; 
(2.)  By  enucleation,  in  which  the  tumour  is  shelled  en  masse  out 

of  its  bed ; 

(3.)  By  the  breaking-do wii  of  its  substance  and  consequent  ex- 
pulsion in  fragments. 

Enucleation  occurs  in  submucous  and  also  in  interstitial  tumours.     The  Spontane- 
mucous  membrane  of  the  capsule  ulcerates,  and  the  tumour  is  thus  "j^"  f cle" 
exposed;  partly  through  suppuration,  partly  thro  ugh  uterine  contractions,  Fibroids, 
it  becomes  detached  all  along  the  line  of  its  capsule  and,  being  thus 
liberated,  is  expelled.     This  process  is  comparatively  safe  for  the  patient, 
though  there  is  always  the  risk  of  haemorrhage  from  the  large  veins  in 
the  capsule  (fig.  251).     In  spontaneous  enucleation,  suppuration  does 
not  occur  in  the  tumour  itself  but  only  in  its  capsule. 

The  breaking-doivn  of  the  substance  of  the  tumour  is  a  much  more  Breaking- 
dangerous  process  for  the  patient.     As  it  is  a  slow  one,  there  is  a  risk  of  pj 
absorption  of  septic  matter.     The  commencement   of  this  change   is 
indicated  by  increase  in  the  size  of  the  tumour,  which  becomes  tense  and 
painful  to  the  touch.     There  is  a  purulent  foetid  discharge  from  the 
vagina,  and  sometimes  haemorrhage.     The  constitutional  symptoms  of 
loss  of  appetite  and  hectic  fever  afterwards  develop,  and  most  of  such 
cases  end  fatally. 

Expulsion  of  the  tumour  generally  takes  place  per  vaginam.  As  in 
other  tumours  we  have  inflammatory  adhesions  forming  with  neighbour- 
ing organs,  followed  by  suppuration  and  perforation  by  the  tumour. 
Thus  calcified  fibroids  have  perforated  into  the  bladder,  and  have  been 

1  He  does  not  refer  to  a  case  observed  by  A.  R.  Simpson,  and  possibly  others  have  been  overlooked. 


420 


AFFECTIONS  OF   UTERUS. 


Causes  of 
Death  in 
Fibroids. 


Diagnosis 
of  Small 
Fibroid 
Tumours. 


mistaken  for  vesical  calculi.1  A  fibroid  has  perforated  into  the  rectum, 
and  has  been  discharged  per  anum.  In  some  cases  adhesions  with  the 
abdominal  wall  have  formed,  and  the  tumour  has  been  thus  discharged. 
Considering  the  frequency  of  fibroid  tumours,  it  is  rare  that  death 
follows  immediately  from  their  presence.  A  fatal  result,  however,  may 
follow  from  (1)  suppuration  in  the  tumour  producing  death  from  septi- 
caemia, or  a  septic  peritonitis ;  (2)  uraemia,  due  to  compression  of  the 
ureters ;  (3)  direct  haemorrhage  ;  (4)  acute  simple  peritonitis. 

PHYSICAL  SIGNS:  DIFFERENTIAL  DIAGNOSIS. 
The  physical  signs  of  fibroid  tumours  are  usually  so  well  marked  that 
diagnosis  is  easy.  In  certain  cases,  however,  diagnosis  is  very  difficult ; 
and  when  inflammation  is  superadded,  certainty  is  impossible.  Physical 
diagnosis  is  best  considered  under  two  heads :  a.  of  small  fibroid 
tumours,  up  to  the  size  of  a  walnut  or  egg ;  6.  of  larger  ones,  which 
rise  up  as  distinct  tumours  into  the  abdomen. 

a.   OF    SMALL    FIBROID    TUMOURS. 

1.  Pediculated  mbmucous  fibroids  should  be  easily  recognised.     When 
they  are  small  and  not  projecting  through  the  os,  we  have  to  dilate  the 
cervix  to  ascertain  their  presence  and  attachment ;    when  larger  and 
projecting  into  the  vagina,  they  may  readily  be  mistaken  for  inversion 
of  the  uterus.     On  sweeping  the  finger  round  the  base,  we  recognise  the 
commencement  of  the  cervical  canal  unless  the  polypus  be  adherent  at 
its  neck  leading  to  obliteration  of  the  canal  (v.  fig.  232).     Further,  the 
bimanual  or  rectal  examination  shows  the  fundus  uteri  to  be  in  its 
normal  position. 

2.  Small  interstitial  fibroids  when   situated   low   doivn  and    causing 
bulging  of  one  lip  of  the  cervix,  give  rise  to  difficulty ;  owing  to  the 
great  enlargement  of  one  lip,  the  os  is  displaced  to  the  other  side  and 
its  form  altered  to  that  of  a  mere  slit  which  easily  escapes  observation. 
Such  cases  have  been  occasionally  mistaken,  even  by  the  most  experi- 
enced for  inversion.     This  mistake    is  prevented  by  examination  per 
rectum.     Further,  the  sides  and  base  of  the  tumour  must  be  carefully 
scrutinised  to  discover  the  os ;  when  this  is  found,  the  sound  will  show 
the  position  of  the  uterine  cavity. 

3.  Interstitial  fibroids  placed  high  up  in  the  uterus,  or  small  subserous 
ones  with  a  broad  base  of  attachment,  often  escape  detection.     To  ascer- 
tain their  presence  we  proceed  as  follows.     Pass  the  sound  ;  this  defines 
the  course  of  the  uterine  canal  and  position  of  the  fundus.     Now  make 
the  bimanual  examination  with  the  sound,  as  represented  in  fig.  90 ; 
the  finger  in  the  anterior  fornix  detects  the  th^kening  of  the  anterior 
wall,  produced  by  a  small  fibroid.     Now  steady  the  sound  with  the  left 

1  M'Clintock— J>ub.  Quart.  Jour.,  Feb.  1868. 


DIFFERENTIAL  DIAGNOSIS  OF  FIBROID  TUMOURS.  421 

hand,  and  pass  the  forefinger  of  the  right  hand  into  the  rectum  so  as  to 
feel  the  sound  lying  in  the  uterus.  Should  there  be  a  fibroid  in  the 
posterior  wall,  the  finger  recognises  an  unusual  thickness  of  tissue 
between  it  and  the  sound.  Carry  the  sound,  firmly  grasped  by  the  left 
hand,  towards  the  symphysis,  so  as  to  bring  the  fundus  better  within 
reach  of  the  rectal  finger ;  and,  by  moving  it  from  side  to  side,  ascertain 
whether  the  tumour  is  intimately  connected  with  the  uterus  so  that  it 
moves  along  with  it.  From  their  being  largely  composed  of  fibrous 


FIG.  252. 

CASE  OF  TWO-AXD-A-HALF  MONTHS'  PREGNANCY  ASSOCIATED  WITH  TWO  LARGE  FIBROID  TUMOURS — 
one  in  the  anterior,  the  other  in  the  posterior  wall.  The  uterus  and  tumours  were  removed  by 
Laparotomy  (Barnes). 

tissue,  these  tumours  are  firmer  than  the  uterine  wall ;    the  localised 
hardness,  therefore,  helps  us  in  recognising  them.  Differential 

Small  fibroid  tumours,  when  submucous  or  interstitial,  require  to  be^g^jj18 

diagnosed  from  chronic  metritis,  Fibroid 

Tumours, 
early  pregnancy, 

ante-  and  retro-flexion. 
When    subperitoneal  and   pediculated  they  must    be  differentiated 


422  AFFECTIONS  OF  UTERUS. 

from  enlarged  Fallopian  tube  or  ovary, 

tumour  or  inflammatory  collection  in  the  broad  ligament. 

In  chronic  metritis  the  uterus  is  not  globular  but  flat,  and  the 
enlargement  is  equable ;  the  uterine  canal  is  patulous ;  the  os  is  everted, 
and  shows  catarrhal  patches.  We  must  remember  that  chronic  metritis 
is  occasionally  present  along  with  a  fibroid  tumour. 

In  early  pregnancy,  the  uterus  is  soft  and  elastic :  the  cervix  is 
generally  softened,  while  in  fibroids  it  remains  hard.  Pregnancy,  how- 
ever, may  occur  in  a  uterus  which  is  already  the  seat  of  a  fibroid  tumour 
(fig.  252) ;  and  in  such  a  case  the  diagnosis  becomes  certain  only  after 
the  uterus  is  considerably  enlarged.  The  possibility  of  pregnancy  must 
specially  be  kept  in  mind  here,  as  we  involuntarily  think  of  using  the 
sound  to  aid  in  detecting  fibroids. 

Anteflexion  is  closely  simulated  by  a  fibroid  in  the  anterior  wall;  a 
body  is  felt  in  the  anterior  fornix,  continuous  with  it,  but  separated  by  a 
groove.  Similarly,  a  fibroid  in  the  posterior  wall  has  all  the  characters 
of  the  retroflexed  fundus.  Examination  by  the  sound  (v.  fig.  204),  and 
especially  by  the  sound  plus  the  Bimanual,  clears  up  the  case. 

Enlarged  Fallopian  tube1  or  ovary  may  closely  resemble  a  pedicu- 
lated  subserous  fibroid ;  they  are  not  so  firm  and  sharply  defined,  nor  do 
they  move  so  rigidly  with  the  uterus.  In  the  former  also  there  are  the 
history  and  symptoms  of  tubal  disease.  Inflammatory  collections  in  the 
broad  ligament  are  recognised  by  their  history,  the  fixation  of  the 
uterus,  and  the  changes  they  undergo  ;  but  solid  tumours  there  cannot 
be  diagnosed  from  pediculated  fibroids  except  by  exploratory  incision. 

6.    OF    LARGE    TUMOURS. 

When  the  tumour  extends  into  the  abdomen,  we  proceed  with  the 
systematic  examination  as  described  at  page  90. 

Diagnosis  Palpation.  The  tumour  has  a  well-defined  outline,  and  a  firm  solid 
Fb^iP  consistence.  It  is  intimately  connected  with  the  uterus;  this  is  best 
Tumours,  ascertained  by  laying  hold  of  the  cervix  with  the  volsella,  when  the 
cervix  will  be  found  to  move  along  with  the  abdominal  tumour.  Sub- 
serous  fibroids  have  a  certain  range  of  free  movement  depending  on  the 
length  of  the  pedicle.  In  soft  fibroids,  there  may  be  intermittent 
contractions.  Percussion.  The  note  is  absolutely  dull,  unless  intestines 
come  between  the  tumour  and  the  abdominal  wall.  Auscultation.  The 
uterine  souffle  is  heard  most  distinctly  at  the  sides,  sometimes  all  over 
the  tumour.  As  the  uterine  souffle  simply  means  enlarged  uterine 
arteries,  there  is  no  souffle  when  these  are  not  enlarged ;  hence  it  is 
absent  in  subserous  fibroids  with  a  small  pedicle.  Vaginal  examina- 

1  Horrocks  discusses  this  point  in  differential  diagnosis  in  the  Brit.  Met.  Journ.,  1888,  I.  pp.  441, 
586,  821. 


DIFFERENTIAL  DIAGNOSIS  OF  FIBROID  TUMOURS.  423 

tion.  Should  the  tumour  be  large  and  lifting  the  uterus  into  the 
abdomen,  the  cervix  will  be  high  up ;  or  it  may  be  displaced  in  various 
ways,  according  to  the  position  of  the  tumour ;  it  has  a  firm  consistence. 
Bimanual.  With  pediculated  subserous  fibroids,  the  uterus  is  felt 
distinct  from  the  tumour;  with  interstitial  and  submucous,  we  simply 
feel  a  large  mass  continuous  with  the  cervix.  The  Sound.  This  should 
not  be  used  till  all  possibility  of  pregnancy  has  been  excluded.  In 
doubtful  cases,  we  wait  three  or  four  months  till  the  positive  signs  indi- 
cative of  pregnancy  should  have  had  time  to  develop.  From  the  use  of 
the  sound  we  learn  (1)  the  length,  (2)  the  direction  of  the  uterine 
cavity.  The  length  of  the  cavity  is  always  increased  in  submucous,  and 
generally  in  interstitial,  but  not  in  subserous  tumours ;  it  may  measure 
six  or  eight  inches.  The  direction  of  the  canal  is  often  tortuous  in  sub- 


FIG.  253. 

SOUXD   USED   TO   DETECT   PEDICULATED   SUBMUCOUS   FlBROID  (Leblond). 

mucous  tumours ;  hence  the  passage  of  the  sound  is  difficult,  sometimes 
impossible.  We  feel  that  the  sound  goes  so  far  and  then  catches  on  a 
hard  projection.  In  such  cases,  a  soft  (No.  8)  bougie  is  very  useful,  as 
its  flexibility  allows  it  to  pass  the  obstruction.  Usually,  the  sound  passes 
to  only  one  side  of  the  tumour ;  sometimes  we  can  sweep  it  more  or  less 
round  the  tumour,  showing  that  it  projects  free  into  the  uterine  cavity 
(fig.  253). 

Large  fibroid  tumours  require  to  be  diagnosed  from —  Differential 

,  Diagnosis 

Advanced  pregnancy,  of  Large 

Ovarian  tumours,  Fibroid 

Tumours. 
Extra-uterine  gestation, 

Haematocele  and  inflammatory  deposits. 


424  AFFECTIONS  OF  UTERUS. 

In  advanced  pregnancy  the  uterus  is  of  softer  consistence,  and  shows 
ballottement — the  indication  of  a  solid  within  a  fluid ;  further,  we  can 
feel  the  parts  of  the  foetus.  It  becomes  occasionally  harder  under  the 
hand,  specially  if  we  make  the  patient  change  her  position ;  this  varia- 
tion in  consistence  is  a  most  valuable  diagnostic,  as  it  is  rarely  present  in 
fibroid  tumours.  We  hear  the  uterine  souffle  and,  unless  the  child  be 
dead,  we  hear  in  addition  the  foetal  heart;  the  possibility  of  the  child's 
being  dead  should  always  be  kept  in  mind.  On  vaginal  examination, 
there  is  discoloration  of  the  vaginal  walls  with  free  secretion ;  the  cervix 
is  softened.  There  is  usually  amenorrhosa  corresponding  in  duration  to 
the  size  of  the  uterus. 

The  diagnosis  is  not  so  easy  as  it  appears  on  paper ;  witness  a  case1  in  which  abdo- 
minal section  was  about  to  be  done  in  a  case  of  four  months'  pregnancy,  which  was  not 
recognised,  on  the  most  careful  examination,  until  the  patient  was  under  the  anaesthetic. 
Such  a  case  shows  the  necessity,  in  doubtful  cases,  of  anaesthesia  even  for  examination. 

Ovarian  tumours  are  soft  and  elastic  ;  small  ones  may  be  firm.  There 
is  no  uterine  souffle.  They  only  give  rise  to  difficulty  in  diagnosis  when 
they  have  become  adherent  to  the  uterus,  and  move  along  with  it.  It 
is  sometimes  impossible  to  diagnose  between  them  and  cystic  fibroid 
tumours  (v.  Fibro-cystic  Tumours). 

Extra-uterine  gestation  presents  great  difficulty  in  diagnosis,  especially 
when  the  gestation  is  in  an  undeveloped  horn  of  the  uterus.  This  con- 
dition may  so  closely  simulate  a  fibroid  that  it  may  not  be  diagnosed 
till  Abdominal  Section  has  been  made  (v.  p.  263).  But  we  delay  its 
consideration  till  the  chapter  on  that  subject. 

In  hcematocele  and  inflammatory  deposits  we  have  the  history  of  the 
attack  to  guide  us.  It  may  be  impossible  to  form  a  diagnosis  on  first 
examination ;  but  after  watching  the  case  for  a  few  weeks  and  noting 
any  change  in  the  deposit  in  addition  to  ascertaining  its  precise  situa- 
tion, we  can  form  a  diagnosis.  Pelvic  peritonitis  frequently  occurs  round 
a  subperitoneal  fibroid,  or  any  fibroid  producing  pressure ;  and  in  such 
a  case  it  is  impossible  to  diagnose  between  the  tumour  and  the  effusion 
round  it.  Many  cases  reported  of  gradual  absorption  of  a  fibroid 
tumour  under  treatment  were  probably  cases  of  mistaken  inflammatory 
exudation. 

PROGNOSIS. 

In  forming  our  prognosis  we  must  take  into  account  (1)  the  site  of 
the  tumour  in  the  uterus,  most  favourable  when  subserous;  (2)  its 
position  in  the  pelvis,  whether  low  down  and  likely  to  become  wedged 
within  it ;  (3)  the  symptoms  already  present,  of  which  haemorrhage  is 
the  most  important ;  (4)  rapidity  of  growth,  which  by  itself  rarely  forms 
a  reason  for  interference.  Though  (as  already  said)  they  are  rarely 
dangerous  to  life,  they  may  cause  the  patient  many  years  of  suffering 
from  which  she  only  finds  relief  at  the  menopause. 

1  Brit.  Med.  Journ.  1886,  II.  p.  474. 


CHAPTER    XXXVII. 

FIBROID  TUMOURS  OF  THE  UTERUS :  TREATMENT. 

LITERATURE. 

Atlec — The  treatment  of  the  fibroid  tumours  of  the  uterus :  Internat.  Med.  Cong. 
Trans.,  Sept.  1876.  Bantock— British  Medical  Journal,  1881,  p.  426.  Bigdow— 
Gastrotomy  for  Myofibroma  of  the  Uterus  :  Amer.  Jour.  Obstet. ,  Nov.  and  Dec. 
1883,  Jan.  to  March  1884.  Duncan,  Matthews — Diseases  of  "Women :  London,  1883, 
p.  289.  Fritsch — Bechzig  Falle  von  Laparomyomotomie  mit  epikritischen  Bemerk- 
ungen  iiber  die  Methoden  dieser  Operation  :  Volk.  Samml.,  No.  339.  Greenhalgh 
— On  the  use  of  the  actual  cautery  in  the  enucleation  of  fibroid  tumours  of  the  uterus  : 
London  Med.  Chirurg.  Trans.,  Vol.  LIX.  Hegar  u.  Kaltenbach — Die  operative 
Gynakologie  :  Stuttgart,  1881,  S.  416.  Hofmeiei — Die  Myomotomie  :  Stuttgart,  F. 
Enke,  1884.  Keith — Surgical  treatment  of  tumours  of  the  abdomen :  Edinburgh, 
1885.  On  Supra-vaginal  Hysterectomy,  with  remarks  on  the  principle  of  the  Extra- 
peritoneal  method  of  treating  the  pedicle  :  Brit.  Med.  Journ.,  Dec.  8, 1883.  Thirteen 
cases  of  Hysterectomy,  with  remarks  on  Carbolic  Acid  Spray  in  Abdominal  Surgery : 
Brit.  Med.  Jour. ,  Jany.  31,  1885.  Lcblond — Traite  elementaire  de  Chirurgie  gyne  - 
cologique  :  Paris,  ]  878.  Martin — Pathologic  und  Therapie  der  Frauenkrankheiten  : 
"Wien  und  Leipzig,  Urban  und  Schwartzenberg,  1887.  Palmei — Laparotomy  and 
Laparo-Hysterotomy,  their  indications  for  fibroid  tumours  of  the  uterus  :  Americ. 
Gyn.  Trans.,  1880,  p.  361.  Schroedei — Handbuch  der  Krankheiten  der  weiblichen 
Geschlectsorgane :  Leipzig,  F.  C.  "W.  Vogel,  1886.  Simpson,  A.  JR. — The  treatment 
of  fibroid  tumours  of  the  uterus :  Contributions  to  Obstetrics  and  Gynecology, 
Edinburgh,  1880.  Sims,  Marion — On  intra-uterme  fibroids :  New  York  Medical 
Journal,  April  1874.  Thornton — Cases  of  Hysterectomy,  with  remarks  on  the  value 
of  the  Carbolic  Acid  Spray  in  the  operation  :  Brit.  Med.  Journ.,  May  23, 1885.  Wells, 
Spencei — On  Ovarian  and  Uterine  Tumours,  etc.  :  London,  1882.  See  also  references 
in  the  text,  and  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

THIS  is  best  considered  under  the  heads  of  medical  treatment,  including 
that  by  electricity,  and  surgical  treatment. 

MEDICAL  TREATMENT. 

Under  this  head  we  include  the  administration  of  such  medicines  as 
ergot  and  hydrastis  canadensis,  and  the  use  of  electricity. 

There  is  no  medicine  which  acts  immediately  upon  fibroid  tumours  so  Ergot  in 
as  to  cause  disintegration  and  absorption.     We  have,  however,  a  very   lbroids- 
important  remedy  in  ergot  of  rye  ;  the  beneficial  effects  of  this  have  been 
brought  forward  by  Hildebrandt,  *  and  by  A.   R.  Simpson,  whose  paper 
on  the  treatment  of  fibroids  may  be  consulted  for  illustrative  cases. 2     It 
acts  beneficially  in   two   ways — by  checking   their  nutrition   through 

1  Berl.  L-lln.  Wochetuchrift,  1872,  Ko.  25. 

1  Dobronrawow  gives  two  cases  in  which  size  of  tumour  distinctly  diminished — Centralb.  /.  Gyn. 
1886,  S.  16. 


426 


AFFECTIONS  OF  UTERUS. 


Adminis- 
tration of 
Ergotin 
Subcu- 
taneously. 


Bromide 
of  Potas- 
sium in 
Fibroids. 


diminishing  the  amount  of  blood  circulating  to  them,  and  by  favouring 
their  pedunculation  and  expulsion  ;  these  are  both  due  to  its  action  on 
the  unstriped  muscular  fibre  of  the  walls  of  the  uterus  and  coats  of  the 
blood-vessels.1  Success  in  its  use  depends,  according  to  Simpson,  on 
securing  that  the  preparation  of  ergot  used  be  active,  that  it  be  properly 
administered,  and  that  the  case  be  a  suitable  one.  The  formula  for  the 
preparation  which  he  recommends  is — 

R     Ergotinse  3"- 

Aquae  3yi- 

Chloral-hydratis     3ss.         M. 

Three  grains  of  ergotin  are  contained  in  twelve  minims  of  the  fluid, 
which  is  a  good  medium  dose.  Chloral  is  added  to  make  the  solution 
keep ;  but  even  with  this  it  becomes  after  some  weeks  unfit  for  use,  and 
should  therefore  be  made  up  repeatedly  and  in  small  quantities. 

It  is  administered  with  the  ordinary  hypodermic  needle.  Care  must  be  taken  that  the 
syringe  contains  no  air  ;  this  is  best  secured  by  holding  it  with  the  needle  upwards  and 
squirting  out  some  of  the  liquid.  The  injection  is  made  in  the  gluteal  region,  which  is 
readily  done  when  the  patient  is  lying  on  her  side  ;  and  on  the  right  and  left  sides  alter- 
nately, so  as  to  dimmish  the  frequency  of  punctures  in  the  same  region.  Enter  the  needle 
vertically  and  plunge  it  rapidly  deep  into  the  muscle,  the  point  entering  to  the  depth  of 
from  an  inch  to  an  inch  and  a  half ;  now  empty  the  syringe,  and  quickly  withdraw  the 
needle.  After  use,  remember  to  cleanse  the  needle  with  water  and  to  replace  the  wire  in  it. 
The  patient  soon  becomes  accustomed  to  the  prick  of  the  needle  and,  if  it  be  entered  deeply 
into  the  muscle,  there  is  little  fear  of  local  suppuration ;  after  three  years'  experience  we 
have  seen  this  in  but  one  case,  and  this  was  probably  due  to  a  bad  preparation  of  the 
solution.  For  the  first  few  weeks  the  injections  may  be  made  twice  a  week,  afterwards 
only  once  a  week.  The  treatment  is  continued  for  several  months  until  its  effect  is  seen 
in  diminution  of  the  size  of  the  tumour  or,  at  least,  of  the  haemorrhage  from  it.  The 
suitable  cases  are  those  in  which  the  tumour  is  intra-mural  or  submucous ;  "  it  must  be 
surrounded  by  layers  of  muscular  fibre,  sufficiently  developed  to  be  capable  of  being 
excited  to  contraction. " 

When  the  patient  cannot  be  seen  frequently  by  a  physician,  a  friend  or 
a  nurse  should  be  instructed  how  to  apply  the  needle.  Ergotin  can  also 
be  administered  in  the  form  of  pill,  suppository  (4  grs.  in  each)  or  liquid 
extract  (30  drops  thrice  daily).  When  given  by  the  mouth,  however, 
it  does  not  act  so  quickly  or  surely  as  when  given  hypodermically. 

Hydrastis  Canadensis,2  fifteen  minims  to  one  drachm  of  the  tincture 
or  up  to  four  drachms  of  the  liquid  extract,  is  now  being  used  instead  of 
ergot ;  it  does  not  disturb  the  digestive  system  by  causing  constipation 
as  ergot  sometimes  does. 

Bromide  of  potassium  was  recommended  by  Sir  J.  Y.  Simpson,  who 
believed  that  it  had  a  marked  influence  in  checking  the  growth  and 
even  in  reducing  the  size  of  fibroid  tumours.  Being  a  nervine  sedative, 
it  is  useful  in  cases  where  the  only  symptoms  are  discomfort  from  the 

1  Ringer— Srit.  Med.  Journ.,  Jan.  19,  1884. 

1  Rutherford  gives  five  cases  treated  by  it — it  controlled  haemorrhage,  but  had  no  effect  on  size  of 
tumour— Brit.  Med.  Journ.,  1888,  II.  p.  123. 


MEDICAL  TREATMENT  OF  FIBROID  TUMOURS.      427 

presence  of  the  tumour  or  neuralgic  pain.  As  a  prolonged  use  of  the 
bromide  is  generally  necessary,  small  doses  (ten  grains,  three  times  a 
day)  should  be  administered. 

When  the  patient  can  afford  it,  benefit  is  undoubtedly  derived  from  a 
course  of  treatment  of  mineral  waters  (such  as  those  of  Kreuznach)  as 
recommended  for  chronic  metritis. 

In  the  case  of  growing  tumours,  keeping  the  patient  on  a  low  non- 
stimulating  diet  is  beneficial ;  the  full  diet  and  free  use  of  stimulants,  to 
which  a  patient  inclines  to  make  up  for  the  loss  of  blood,  rather  favour 
the  growth  of  the  tumour.1 

The  symptoms  due  to  the  weight  of  the  tumour  may  be  relieved  by 
artificial  support.  Thus  patients  with  a  small  fibroid  often  derive  great 
benefit  from  wearing  a  Hodge  pessary  ;  the  discomfort  of  a  large  abdo- 
minal tumour  is  materially  lessened  by  wearing  a  broad  flannel  bandage. 

When  the  tumour  nearly  fills  the  pelvis  and  is  beginning  to  press 
injuriously  upon  the  bladder  and  rectum,  we  should,  when  possible, 
push  it  up  out  of  the  pelvis  into  the  abdomen ;  this  is  done  before  the 
occurrence  of  pelvic  peritonitis,  which  may  hopelessly  bind  it  within 
the  pelvis.  The  most  favourable  case  for  this  manipulation  is  a 
subserous  fibroid  with  a  distinct  pedicle. 

TREATMENT    OF    FIBROIDS    BY    ELECTRICITY. 

More  than  twenty  years  ago,  Tripier  of  Paris  treated  uterine  fibro- 
mata with  Faradisation,  and  as  far  back  as  1867  Althaus  wrote  in  the 
British  Medical  Journal  on  the  electrolytic  treatment  of  tumours  ;2  while 
in  America  in  1870,  Cutter3  began  to  use  galvanism  for  the  treatment 
of  fibroid  tumours.  It  is,  however,  to  Apostoli  that  the  credit  is  due 
of  elaborating  the  electrical  treatment  of  fibroids  and  bringing  it 
prominently  forward  before  the  profession. 4 

The  technique  will  be  more  fully  described  in  the  chapter  on  Electri- 
city in  the  Appendix.  Here  we  need  only  say  that  the  internal  electrode 
consists  of  a  platinum  rod  the  thickness  of  a  uterine  sound,  sheathed  in 
a  vulcanite  tube  except  over  the  portion  within  the  uterus.  The  external 
electrode  consists  of  a  pad  of  clay  laid  on  the  abdomen,  having  a  copper 
or  leaden  plate  connected  with  the  battery  wire.  The  internal  electrode 
is  usually  negative  unless  haemorrhage  is  the  chief  symptom,  in  which 
case  it  is  made  positive  on  account  of  the  haemostatic  action  of  that 
pole.  The  current  strength  used  varies  from  70  to  100  milliamperes 
for  the  first  application,  increased  afterwards  to  200  or  even  250 
milliamperes. 

1  See  J.  Knowsley  Thornton  on  the  Treatment  of  Uterine  Fibro-myoma — Lancet,  1886,  II.,  p.  811. 

2  See  letter  by  Althaus  in  the  British  Medical  Journal,  18S7,  I.,  p.  1364. 

3  Amer.  Journ.  Obs.,  1888,  p.  384. 

4  In  his  paper  read  at  the  Dublin  meeting  of  the  British  Medical  Association  in  1887,    "On 
the  Treatment  of  Fibroid  Tumours  of  the  Uterus  by  Electricity  with  Observations  and  Complete 
Statistics  of  all  the  Cases  so  treated  from  July  1882  to  July  1887.— Brit.  Mecl.  Jour.,  1887,  II.,  699. 


428  AFFECTIONS  OF  UTERUS. 

Electricity  in  the  treatment  of  fibroids  is  still  on  its  trial.  It  is 
only  two  or  three  years  old,  and  as  yet  we  have  not  data  for  coming  to 
any  definite  conclusion  as  to  its  value ;  and  there  is  a  remarkable 
divergence  of  opinion  on  this  subject.  On  the  one  hand,  we  have 
Keith,  who  has  had  great  success  in  the  removal  of  fibroid  tumours  by 
abdominal  section,  in  one  of  his  most  recent  utterances, x  saying — 

"  Apostoli's  treatment  puts  a  woman  with  a  fibrous  tumour  who  suffers  much  into  the 
position  of  a  woman  with  a  fibrous  tumour  who  does  not  suffer  or  may  be  even  unaware 
of  its  presence.  It  does  not  bring  about  the  disappearance  of  the  tumour,  or  it  does  so 

very  rarely,  but  size  is  lessened  more  or  less — one-half,  one-third,  two-thirds 

"What  I  now  plead  for  is,  that  for  a  time  all  bloody  operations  for  the  treatment  of 
uterine  fibroids  should  cease,  and  that  Dr  Apostoli's  treatment  as  practised  by  him  should 
have  a  fair  trial. " 

On  the  other  hand,  we  have  Steavenson,  who  has  charge  of  the 
Electrical  Department  of  St.  Bartholomew's  Hospital,  writing  recently 
as  follows2 — 

"In  my  paper  referred  to  [St  Bartholomew's  Hospital  Reports],  I  have  said  that 
'compared  with  other  methods  it  is  probably  the  best  short  of  actual  operation.'  I  have 
admitted  that  the  results  are  not  so  brilliant  as  we  could  have  wished,  or  as  we  were  led 
to  hope  they  would  be.  All  the  palliative  modes  of  treatment  of  uterine  fibroids  are 
eminently  unsatisfactory,  and  the  profession  would  have  hailed  with  delight  any  mode 
of  treatment  that  would  have  promised  a  cure.  This  certainly  electricity  does  not 
accomplish,  at  any  rate  with  tumours  of  any  size ;  but  there  is  no  doubt  that  in  the 
majority  of  cases  the  symptoms  are  relieved,  and  one  of  the  most  troublesome  that  yields 
to  electrical  treatment  is  that  of  haemorrhage.  Improvement  will  also  take  place  under 
the  administration  of  ergot  and  by  the  imbibition  of  the  iodo-bromine  waters  of  Kreuznach 
and  Woodhall  Spa.  ...  It  certainly  is  a  question  whether  in  their  case  [i.e.  hospital 
patients]  the  advantage  obtained  by  the  electrical  treatment  is  sufficiently  great  over 
other  modes  of  treatment  as  to  call  for  the  expenditure  of  the  time  and  trouble  necessary 
for  carrying  it  out." 

From  the  foregoing  it  will  be  seen  that  the  application  of  electricity 
to  fibroids  is  in  great  measure  a  treatment  of  symptoms.  It  finds  its 
place  alongside  of  ergotin,  being  perhaps  more  certain,  but,  on  the 
other  hand,  exacting  more  time  and  trouble  in  its  use. 

Looking  over  the  literature,  and  selecting  only  the  reports  of  more 
than  ten  cases  treated  by  this  method,  we  find  the  following  results  : — 

Apostoli 3  mentions  278  cases  of  "fibromata  or  hypertrophy  of  the  uterus,"  treated  by 
"4246  applications  of  the  continued  current  of  electricity" — the  positive  pole  being 
applied  to  the  uterus  or  tumour  2518  times,  and  the  negative  1726.  As  to  results,  he 
says,  "  I  can  affirm  that  when  there  has  been  no  negligence  and  my  advice  has  been 
fully  acted  upon,  95  times  out  of  100  permanent  benefit  has  been  acknowledged. " 

Cutter*  records  details  of  50  cases,  with  the  following  results  :  11  cured,  3  relieved, 
25  arrested,  4  fatal,  7  non-arrest. 

Deletang6  mentions  its  use  in  97  cases,  with  the  result  that  haemorrhage  stopped,  pain 
and  functional  disturbances  were  relieved,  the  fibromata  shrunk,  but  this  last  result  was 
not  invariable. 

1  Brit.  Med.  Jour.,  June  8,  18S9.  2  Lancet,  April  6,  1889. 

3  Brit.  Med.  Jour.,  1887,  II.,  p.  699.  *  Aimer.  Jour.  Obs.,  1887,  p.  113. 

6  Brit.  Med.  Jour.,  1888,  II.,  p.  1412. 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     429 

Skene  Keith1  mentions  13  cases,  in  all  of  which  the  tumour  was  reduced  and  symptoms 
relieved.  In  a  later  article,  Thomas  Keith2  speaks  of  its  having  been  used  in  considerably 
over  100  cases,  the  majority  being  uterine  fibroids ;  in  every  case,  the  tumour  was 
reduced  in  size,  haemorrhage  and  pain  gone,  and  general  health  restored. 

J.  H.  Martin"  mentions  14  cases,  in  which  4  were  benefitted,  5  symptomatically  cured, 
5  completely  cured. 


SURGICAL  TREATMENT. 

This  consists  in  the  removal  of  the  tumour  through  the  vagina,  or 
through  the  abdominal  walls.  Removal  of  the  uterine  appendages  is 
also  done  with  a  view  to  check  haemorrhage  and  the  growth  of  the 
fibroid. 

a.    REMOVAL    THROUGH    THE   VAGINA. 

We  have  seen  that  this  process  takes  place  spontaneously,  either  by  Removal 
pedimculation  and  extrusion  as  a  polypus  or  by  enucleation.     In  oper-of  Polypl' 
ating,  we  simply  favour  these  natural  processes.     The  former  will  be 
described  under  "  Treatment  of  Polypi "  (see  Chapter  XXXIX.). 

We  favour  enucleation  of  the  tumour  (1)  by  dilating  or  dividing  theEnuclea- 
cervix  uteri ;  (2)  by  incision  of  the  mucous  membrane  covering  the  s 
face  of  the  fibroid ;  (3)  by  stimulating  the  uterus  to  contract  and  expel 
it  spontaneously  from  its  bed,  or  by  laying  hold  of  and  forcibly  detaching 
it.     These  might  be  considered  either  as  different  consecutive  operations, 
or  as  successive  steps  in  the  same  operation.4 

The  dilatation  of  the  cervix  is  affected  in  any  of  the  ways  already  described.  Some- 
times this  is  all  that  is  required.  After  dilatation  or  division  of  the  cervix,  the 
haemorrhage  (which  is  usually  the  indication  for  the  operation)  ceases ;  if  the  tumour 
is  in  the  process  of  expulsion,  this  takes  place  more  readily  through  the  dilated  cervix. 

Should  this  operation  be  insiifficient,  we  proceed  next  to  incision  of  the  mucous 
membrane  covering  the  tumour.  The  purpose  is  twofold.  (1.)  It  checks  haemorrhage. 
We  have  referred  to  the  existence  of  venous  sinuses  in  the  capsule  of  the  tumour,  from 
which  profuse  haemorrhage  sometimes  occurs  (v.  fig.  251) ;  when  these  are  cut  through, 
they  retract  and  are  closed  by  thrombi.  After  this  operation  the  haemorrhages  are, 
for  a  long  period  at  least,  checked.  (2.)  It  favours  spontaneous  enucleation  of  the 
tumour,  which  comes  to  protrude  through  the  incised  mucous  membrane. 

The  mucous  membrane  is  incised  either  with  the  bistoury  or  with  the  thermo-cautery 
as  follows.  Carry  a  probe-pointed  bistoury,  which  has  the  lower  half  of  the  blade 
sheathed,  into  the  uterus  through  the  previously  dilated  cervix ;  make  one  or  more 
incisions,  about  an  inch  long  and  from  a  quarter  to  half-an-inch  deep,  upon  the  surface 
of  the  tumour.  The  great  danger  of  the  operation  is  the  introduction  of  septic  matter  ; 
to  diminish  this  risk,  Greenhalgh  employs  the  actual  cautery  with  an  olive-shaped  bulb 
to  incise  the  mucous  membrane  and  at  the  same  time  to  destroy  the  heart  of  the  tumour ; 
he  also  uses  it  to  burn  away,  from  time  to  time,  portions  of  the  tumour  as  they 
protrude  through  the  capsule.  It  is  evident  that  the  cautery  can  be  used  only  when  we 
have  an  interstitial  fibroid  which  has  forced  itself  into  one  lip  of  the  cervix  and 
projects  markedly  into  the  roof  of  the  vagina  (v.  fig.  249) ;  or  when  a  submucous  fibroid 


1  Edin.  Med.  Jour.,  xxxiii.,  I.,  p.  470,  and  xxxiii.,  II.,  pp.  670  and 

-  Brit.  Med.  Jour.  1887,  II.,  p.  1258.  3  Amer.  Jour.  Obi.,  1888,  p.  (543. 

4  Matthews  Duncan — Edin.  Med.  Jour.,  Feb.  1867. 


430  AFFECTIONS   OF   UTERUS. 

has  dilated  the  os  sufficiently  to  become  accessible  to  the  cautery.  The  cautery,  of 
which  the  Paquelin  is  the  most  convenient  form,  reduces  the  dangers  of  haemorrhage 
and  septic  infection  to  a  minimum. 

The  separation  of  the  tumour  should  be  le  t  to  the  natural  efforts,  and  may  extend 
over  a  period  of  months  ;  during  this  time,  to  promote  uterine  contractions,  the  patient 
is  kept  fully  under  the  influence  of  ergot.  Greenhalgh  remarks  that  "spontaneous 
expulsive  efforts  shortly  followed  the  use  of  the  cautery." 

Should  sloughing  of  the  tumour  occur  during  the  process  of  natural  enucleation,  we 
interfere  to  remove  the  tumour  rapidly.  Even  although  there  is  no  sloughing  it  is 
sometimes  necessary  to  shell  the  tumour  out  of  its  bed.  The  detachment  of  the  tumour 
from  its  capsule  may  be  effected  by  A.  R.  Simpson's  nail  curette  (fig.  254).  It  is  intended, 
as  its  name  implies,  as  a  substitute  for  the  finger  nail  which  would  be  the  best  instru- 
ment were  it  only  strong  enough  to  scrape  through  the  tissues.  Thomas  lias  devised  a 
similar  instrument  which  has  the  form  of  an  elongated  spoon  with  a  serrated  edge  ;  it  is 
worked  with  a  pendulum-like  movement  of  the  hand.  The  advantages  claimed  for  it  are 
that  it  limits  haemorrhage  and,  from  its  concave  form,  "  hugs  the  tumour  "  so  as  not  to 
cut  deeply  into  the  uterine  wall.  Before  operating,  he  measures  with  a  whalebone  probe 
the  extent  of  attachment  of  the  tumour  to  the  wall  of  the  uterus.  He  has  ' '  operated 
more  than  twenty  times  with  this  spoon-saw,  and  its  efficiency  becomes  more  and  more 
apparent  with  increasing  experience. " 

Dangers  of      With  regard  to  enucleation  and  removal  per  vaginam,  from  the  risks 

tion? '       °f  the  operation,  it  is  now  done  only  when  the  symptoms  justify  a 

critical  operation1  or  when  nature  has  begun  but  is  unable  to  complete 


FIG.  254. 

A.  R.  SIMPSON'S  NAIL  CURETTE  <j  (A.  R.  Simpson). 

the  process  of  expulsion.  The  circumstances  most  favourable  for 
removal  by  this  means  are  when  the  tumour  is  small  and  loosely 
connected  with  the  uterus,  or  when  it  has  been  already  "  born  "  into  the 
lax  and  roomy  vagina  of  a  multipara. 

In  addition  to  the  difficulties  of  removal,  the  great  risk  is  septicaemia 
from  the  sloughing  fragments. 

b.  REMOVAL  THROUGH  THE  ABDOMINAL  WALLS  BY  LAPAROTOMY. 

In  the  removal  of  fibroid  tumours  by  laparotomy,  there  have  to  be 
considered  various  methods  of  operation  which  must  be  kept  quite 
distinct,  especially  in  judging  of  the  results  of  myomotomy — as  these 
present  all  degrees  from  a  simple  to  a  complicated  and  critical  operation. 

The  methods  vary  according  as  we  have  to  do  with  a  tumour  which  is 
(1)  subserous  and  pediculated ;  or  (2)  growing  from  the  serous  aspect 
but  between  the  layers  of  the  broad  ligament  or  into  the  cellular  tissue, 
or  (3)  growing  within  the  substance  of  the  wall. 

1  Kleinwachter  makes  the  mortality  15  p.  c.  or  22  out  of  147  cases  which  he  has  collected—  Wien. 
Hied.  Presse,  No.  42,  1887. 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     431 

In  the  case  of  subserous  pediculated  tumours,  the  pedicle  can  be 
treated  intra-peritoneally  as  in  ovariotomy,  i.e.  transfixed  and  ligatured 
in  two  portions,  though  it  is  desirable,  in  addition,  to  bring  together 
with  catgut  the  edges  of  the  peritoneum  over  the  end  of  the  stump; 
or  the  extra-peritoneal  method,  to  be  presently  described,  may  be 
adopted. 

Statistics  for  this  operation  are  difficult  to  gather,  as  simple  myomotomies  are  mixed 
up  with  hysterectomies  in  the  reports  of  operators.  Hofmeier  mentions  21  cases  with  2 
deaths  from  Schroeder's  clinique  ; l  Martin  had  10  with  3  deaths ;  and  Tauffer  8,  all  of 
which  were  successful. "  Bantock  in  his  last  series  of  one  hundred  cases  of  abdominal 
section  specified  nine  cases  in  which  the  pedicle  was  treated  extra-peritoneally  with  the 
serre-noeud  and  all  recovered.  3  In  going  over  the  literature,  we  have  come  upon  other 
cases  by  Albert,  Hill,  Kelly,  Kiimmell,  Mann,  Munde,  Tait,  and  others. 

The  second  class  of  tumours  demands  a  more  serious  operation, 
implying  their  enucleation  from  the  peritoneum  or  cellular  tissue.  The 


FIG.  255. 

MARTIN'S  OPERATION  FOR  ENUCLEATION  OF  FIBROID  FROM  WALL  OF  XJTERUS  (Martin). 

a.  Shows  uterus  with  temporary  elastic  ligature  roimd  it ;  the  shaded  portion  of  capsule  being  the 

extent  of  incision  in  it.     b.  Shows  how  the  hollow  in  uterine  wall  is  closed  by  sutures. 


cavity  thus  produced  may  be  either  sewed  up  with  catgut  and  the 
abdominal  incision  closed ;  4  or  its  margins  may  be  stitched  to  the  open 
abdominal  wound,  the  hollow  being  packed  with  iodoform  gauze.5 

The  third  condition,  when  the  fibroid  is  in  the  substance  of  the  wall, 
gives  occasion  for  two  quite  distinct  methods  of  operation — enucleation 
from  the  wall,  and  hysterectomy. 

1 .  Enucleation  of  the  tumour  from  the  uterine  ivall  with  sewing  up  of  the 
hollow  thus  produced  is  an  operation  introduced  by  Martin  of  Berlin. 
The  cases  in  which  it  can  be  done  are  limited ;  but,  where  it  is  possible, 
it  has  the  double  advantage  of  being  a  less  serious  operation  than 
hysterectomy  and  not  mutilating  the  uterus.  He  has  done  it  sixteen 

1  Hofmeier — Loc.  cit. 

2  Dirner—  Centralb.f.  Gyn.  Vol.  XI.  S.  98. 

3  Lancet,  1887,  I.,  p.  518. 

4  As  in  recent  cases  by  Baumgartner  and  Veit — Centralb.  f.  Gi/n.,  Bd.  XI.,  S.  771. 

5  As  in  Kokitansky's  case — Ibid.  S.  839. 


432  AFFECTIONS   OF  UTERUS. 

times, l  with  three  deaths  in  the  first  five  cases  and  none  in  the  last 
eleven. 

After  the  uterus  has  been  exposed  by  abdominal  section  and  drawn  forward  into  the 
incision,  a  temporary  elastic  ligature  is  thrown  round  the  broad  ligaments ;  this  is  not 
necessary  in  all  cases,  as  with  a  mesial  incision  the  bleeding  may  be  but  slight.  A 
longitudinal  incision  is  made  over  the  tumour  which  is  shelled  out  of  its  capsule  :  the 
margins  of  the  cavity  are  then  trimmed  with  scissors,  considerable  portions  of  the 
muscular  wall  and  all  the  connective  tissue  portion  of  the  capsule  being  sometimes 
excised ;  and  the  wound  is  closed  by  continuous  deep  and  superficial  juniper  catgut 
sutures.  The  uterine  cavity  may  be  opened  into  during  the  operation,  but  if  it  be 
disinfected  or  packed  with  iodoform  gauze2  (extending  down  into  the  vagina  for  ease  of 
removal)  which  acts  as  a  drain,  it  does  not  affect  the  prognosis,  (v.  fig.  255.) 

Frankel  in  an  elaborate  paper  on  this  operation  makes  twenty-four 
cases  reported  on  (by  Martin,  Schroeder,  Huge,  Veit,  Hegar,  and 
himself),  with  six  deaths  or  a  mortality  of  25  p.c.  Going  over  the 
literature  given  in  the  Index  in  the  Appendix,  we  have  come  on  five 
cases  of  a  similar  operation  (enucleation  of  a  tumour  from  the  uterus 
with  sewing  up  of  the  wound  in  it)  by  Freund,3  Karstrom,4  Rein,5  in  all 
of  which  there  was  recovery. 

2.  Hysterectomy. — By  hysterectomy  we  mean  that  a  portion  at  least  of 
the  uterus  is  cut  away  with  the  tumour,  leaving  a  stump  of  cervix  and 
more  or  less  of  body  of  uterus  (with  its  cavity  cut  across)  according  to  the 
height  of  the  tumour  in  the  uterine  wall.  Strictly  speaking,  this  is  only 
a  "  supra- vaginal  amputation  ; "  but  the  term  "  hysterectomy  "  has  come 
into  use  and  is  convenient  if  we  remember  that  only  in  very  rare  cases <: 
is  the  whole  uterus  cut  out. 

HYSTERECTOMY    FOR    FIBROIDS. 

This  operation  may  be  divided  into  three  stages  : — (1)  The  opening 
into  the  abdominal  cavity,  (2)  the  extraction  of  the  tumour,  (3)  the 
treatment  of  the  stump. 

1.  The  opening  into  the  abdominal  cavity  is  made  as  in  ovariotomy, 
but  the  incision  may  in  some  cases  extend  from  ensiform  cartilage  to 
pubes   (v.   Chap.    XXIV.).     The   bladder  is  sometimes   high   up   and 
may   have   to   be   separated   off  the   tumour.     As   it   is   more   easily 
defined  when  distended,  it  should  not  be  emptied  before  the  opera- 
tion. 

2.  The  tumour  is  brought  out  through  the  abdominal  incision.     When 
the  mass  is  large,  it  may  be  difficult  to  draw  the  slippery  tumour  out ; 
to  have  purchase  on  it,  Thornton  screws  a  nickel-plated  corkscrew  with 
a  broad  blade  into  it.      Pean  diminishes  the   size  of  the  tumour  by 

1  From  1880  to  1886.     See  Czempin — Ueber  die  Enucleation  intraparietaler  Myome  nach  A.  Martin : 
Zeiti.f.  deb.  u.  Gyn.,  Bd.  XIV.,  S.  223.     Five  still  more  recent  cases  by  Martin  are  mentioned  but 
not  reported  on. 

2  As  Frankel  did  in  his  two  cases — Ueber  die  Enucleation  submucoser  oder  intraparietaler  Myome 
von  der  Bauchhole  aus  (Martin'scbe  Operation),  etc. :  Archivf.  Gyn.  Bd.  XXXIII.,  S.  449. 

3  Centralb.f.  Gyn.,  Bd.  XII.,  S.  801.  *  Ibid.,  Bd.  XL,  S.  647.          5  Ibid.,  Bd.  XII.,  S.  852. 
°.  Dixon  Jones  has  recently  recorded  one  (Amer.  Jour.  Obs.,  1888,  p.  604). 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     433 

"  morcellement  "—cutting   off  portions  with   the   wires   of  the   serre- 
nceud. 

3.  The  treatment  of  the  stump  is  by  either  the  intra-peritoneal  or  the 
extra-peritoneal  method. 

In  the  intra-peritoneal  method,  the  stump  after  being  ligatured  is,  as  Intra-peri- 
already  said,  dropped  into  the  peritoneal  cavity  as  in  ovariotomy ;  in  the  Tre6  tment 
extra-peritoneal,  the  stump  is  brought  into  the  abdominal  incision  and  ?f  Pedicle 
fixed  there  so  as  to  be  outside  of  the  peritoneal  cavity.  otomy'for 

Schroeder,  Martin,  and  some  other  operators  prefer  the  former  plan. 
Schroeder,  who  was  a  great  advocate  of  this  method,  proceeded  as 
follows  : — 

The  ovarian  arteries — the  course  of  which  is  seen  in  Plate  VI. — were  first  ligatured  on 
each  side.  These  can  be  recognised  by  feeling  their  pulsation  with  the  finger ;  or  by 


FIG.  256. 

SUPRA-VAGINAL  AMPUTATION  OF  UTERUS  FOB  FIBROID  TUMOUR  (Martin). 

This  shows  two  modes  of  treating  the  Broad  Ligament  before  going  on  to  amputation.  On  the  left 
side,  the  elastic  ligature  is  placed  above  the  infundibulo- pelvic  ligament— the  Ovary  and  Tube 
having  been  tied  and  separated.  On  the  right  side,  the  Broad  Ligament  has  been  tied  in  two 
places  (each  ligature  forming  three  loops)  and  divided  between  them  so  as  to  allow  the  elastic 
ligature  to  get  close  up  to  the  uterus.  The  dark  lines  show  Martin's  lines  of  excision — the 
vertical  to  take  out  the  tumour,  the  transverse  to  amputate  uterus  and  make  the  stump. 

holding  the  ligament  against  the  light,  when  their  course  is  easily  seen.  A  double  silk 
ligature  was  carried  on  a  needle  from  behind  through  the  cervix  so  as  to  come  out  at  the 
bottom  of  the  vesico-uterine  pouch  in  front ;  this  was  divided  and  the  end  of  each  half 
carried  backwards  through  the  broad  ligament  of  its  respective  side,  just  external  to  the 
cervix,  and  knotted  to  its  corresponding  end  ;  the  cervix  was  thus  tied  in  two  portions, 
each  uterine  artery — the  position  of  whichis  seen  in  Plate  VI. — being  controlled  by  a  liga- 
ture. The  tumour,  with  the  body  of  the  uterus  and  the  ovaries,  was  cut  away  rapidly, 
with  a  large  knife,  above  the  ligatures.  The  uterine  stump  was  cut  in  a  V  shape  ;  and 
first  the  muscular  walls  were  adapted  with  coarser,  then  the  peritoneal  covering  with 
finer  silk  sutures. 

Martin,  who  also  has  adopted  the  intra-peritoneal  method,  uses  the 
2  E 


434  AFFECTIONS  OF  UTERUS. 

elastic  ligature  to  constrict  the  uterus  before  suturing  the  stump.  As 
it  is  difficult  to  get  the  ligature  to  clasp  the  lower  segment  of  the  uterus 
owing  to  the  opposing  tension  of  the  broad  ligaments,  these  have  to  be 
divided  first  (v.  fig.  256).  The  mass  is  next  incised  longitudinally  (v. 
fig.  256)  and  the  tumour  turned  out.  The  uterus  is  then  amputated, 
the  line  of  incision  running  slightly  downwards  from  the  sides  so  as  to 
be  half  an  inch  above  the  elastic  ligature  in  the  mesial  line.  The  cavity 
cut  into,  whether  of  body  or  cervix,  is  cleansed  with  1  p.c.  solution  of 
perchloride  of  mercury  and  then  sewed  up  (v.  fig.  257).  Finally,  the 
cup-shaped  hollow  of  the  stump  is  closed  with  deep  silk  sutures  and 
superficial  catgut  ones.  An  opening  is  made  from  the  pouch  of  Douglas 
into  the  posterior  fornix  and  a  drainage  tube  inserted.  Zweifel1 
recommends  tieing  the  pedicle  in  three  or  four  separate  portions  and 
then  stitching  the  peritoneum  over  the  end  of  it :  he  ties  the  broad 
ligaments  first  and  then  separates  them  from  the  uterus;  after  this, 


FIG.  257. 

SUPRA- VAGINAL  AMPUTATION  OF  UTERUS  (Martin). 

This  shows  deep  stitches  closing  cervical  canal  (a),  and  position  of  sutures  (of  which  some  are 
deep  and  others  superficial)  closing-in  muscular  wall  and  peritoneum. 

the  elastic  ligature  is  applied  temporarily  and  the  tumour  cut  away,  and 
the  stump  then  transfixed  and  ligatured  in  three  or  four  pieces. 

Dixon  Jones  2  has  recorded  recently  a  successful  case  of  this  operation 

in  which  she  separated  the  uterus  below  from  its  attachments  to  the 

vagina,  clamped  the  broad  ligaments  with  forceps  which  were  left  in  the 

vagina  and  served  also  to  drain  the  peritoneal  cavity. 

Extra-peri-     The  extra-peritoneal  method  has   been  carried  out  by  the  following 

Treatment  means : — 

of  Pedicle  m,      .. 

in  Lapar-  The  ligature  or  clamp, 

Fibroid?*  The  Clamp  and  cauterv> 

The  serre-noeud, 

The  elastic  ligature. 

1  ArcUvf.  Qyn.  XXXII.  S.  473.     He  has  treated  the  last  9  of  23  cases  thus  and  with  the  lest 
results. 
1  Amer.  Jour.  Obstet.,  1888,  p.  004. 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     435 

The  extra-peritoneal  method  was,  we  believe,  first  attempted  by 
Spencer  Wells.  Comparing  the  two  methods,  he  says,  "  When  it  has  Clamp, 
been  possible  to  secure  the  pedicle  and  fix  it  outside  the  wound  in  the 
abdominal  wall,  the  result  has  been  much  more  satisfactory."  Of  28 
cases,  in  which  the  method  is  specified,  15  were  extra-  and  13  intra- 
peritoneal.  In  6  of  the  15  cases,  the  pedicle  was  retained  in  the  wound 
by  means  of  a  clamp  ;  in  the  rest  by  means  of  the  ligature,  aided  in  some 
cases  by  use  of  a  pin. 

The   searing   of  the  stump  with    the   actual   cautery   without   any  Clamp  and 
ligatures,  is  the  modification  of  the  extra-peritoneal  method  adopted  Cautery* 
by  Thomas.     He  uses  a  damp  to  arrest  haemorrhage  during  the  amputa- 
tion of  the  uterus  and  while  the  pedicle  is  being  seared.      It  is  in 
two  separate  portions ;   the  one  half  is  placed  below  the  neck  of  the 
tumour  or   uterus,   and   the  other   then  adapted  to   it   and   screwed 


FIG.  258. 
PLAN'S  CURVED  NEEDLE  FOR  CARRYING  THE  WIRES  THROUGH  THE  STUMP  OF  THE  CERVIX  (Leblond). 

down.  To  prevent  retraction  of  the  pedicle,  it  is  before  cauterisation 
transfixed  above  the  clamp  with  long  wire  needles.  After  cauterisation 
the  clamp  is  loosened,  but  left  in  situ  for  fourteen  days  so  as  to  be 
screwed  up  should  haemorrhage  occur. 

The  extra-peritoneal  method  has  met  with  great  success  in  the  hands  Serre- 
of  Pean  of  Paris,  who  has  the  merit  of  having  elaborated  it  as  a  distinct nceud- 
method.     He  operates  as  follows.     The  tumour  having,  if  necessary, 
been  reduced  by  "morcellement,"  it  is  drawn  out  of  the  abdomen  and 
held  perpendicularly  by  an  assistant.     The  operator,  having  ascertained 
with  a  sound  the  relations  of  the  bladder  (which  only  in  rare  cases 
requires  to  be  dissected  off),  transfixes  the  cervix  with  two  strong  wires 
at  right  angles  to  each  other.     Below  these  wires,  the  curved  needle 
represented  at  fig.  258  is  carried  through  the  cervix  and  drags  back 


436 


AFFECTIONS  OF  UTERUS. 


Keith's 
Method. 


fixed  by 
up,    but 


a  double  wire.  This  wire  is  divided,  and  each  half  is  fitted  into  a 
serre-rweud  of  Cintrat  (fig.  259)  by  means  of  which  it  is  both  tightened 
and  twisted.  The  tumour  and  uterus  are  amputated  above  the  wires. 
The  pedicle  is  placed  in  the  abdominal  wound,  and  is  kept  from 
retracting  into  the  abdomen  by  means  of  the  wire  and  the  serre-noeud  ; 
these  are  left  in  position  so  that  they  may  be  tightened  in  case  of 
haemorrhage. 

In  Koeberle's  serre-nceud  (the  one  generally  used  in  this  country) 

the  wire  is  not 
twisting 
the  in- 
strument and  wire 
are  left  on  the 
stump  so  that  the 
loop  can  be  further 
tightened  up  at 
any  time.  Polk1 
advises  stripping 
down  the  perito- 
neum round  the 
stump  so  as  to 
place  the  wire  be- 

FIG.  259.  tween  the  former 

and  the  muscular 
tissue,  thus  treat- 
ing the  stump  like 
an  enucleated  par- 
ovarian  cyst. 

Keith,  who  has 
had  the  best  re- 
sults of  any  operator,  says  with  regard  to  the  treat- 
ment of  the  pedicle,2  "I  have  no  one  way  in  dealing 
with  the  attachments  of  uterine  tumour.  At  present 
each  case  must  be  a  law  unto  itself,  and  of  this  part 
of  the  operation  there  is  much  to  be  learned.  A  few 
of  the  simpler  cases  may  be  treated  entirely  extra- 
peritoneally.  Generally  the  broad  ligaments  must 
be  left  inside ;  and  sometimes  the  whole  attach- 
ment, when  there  is  much  enucleation,  must  be  so 
treated.  Sometimes  the  treatment  may  be  entirely  intra-peritoneal  by 
means  of  Koeberle's  serre-noeud,  or  it  may  be  half  intra-  and  half  extra- 
peritoneal.  These  cases  require  much  care  in  the  after-dressing,  though 
the  convalescence  is  much  shorter  than  when  the  whole  is  left  outside. 


CINTRAT'S  SERRE-NCF.UD  (Hegar).  The  wire 
after  having  been  placed  round  the  neck 
of  the  uterus  or  tumour  is  tied  on  the 
two  knobs  which  travel  on  the  thread 
of  the  screw.  On  turning  the  handle 
when  the  middle  piece  is  held  firm  at 
the  larger  loops,  we  tighten  the  noose ; 
when  the  head  piece  is  held  at  the 
smaller  loops,  we  twist  the  wire.  The 
result  is  seen  to  the  right  hand  side 
(Leblond). 


Artier.  Jour.  Obitet.,  1889,  p.  629. 


z  Brit.  Med.  Jour.,  Jan.  31,  1885. 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     437 


I  am  hopeful  that  the  cautery  will  yet  be  the  best  and  safest  of  all  the 
methods  of  dealing  with  some  of  these  tumours."  In  his  monograph  on 
"  Surgical  Treatment  of  Tumours  of  the  Abdomen,"  he  says,  "  At  first  I 
used  Koeberle's  instrument,  which  is  still  the  best  for  this  purpose ; 
but  for  long  I  have  given  it  up  in  favour  of  a  very  large  thin  clamp, 
and  I  think  that  this  is  a  safer  way. 
I  have  not  found  sloughing  take  place 
to  the  extent  that  it  does  when  a  single 
wire  merely  embraces  the  pedicle.  .  .  . 
Before  applying  the  clamp,  it  is  better 
to  draw  all  the  parts  gently  together  by 
a  thick  silk  ligature  or  by  a  soft  wire. 
This  prevents  a  too  great  spreading  out 
of  the  parts  between  the  blades,  which 
would  render  the  closing  of  the  wound 
around  the  clamp  somewhat  trouble- 
some. As  soon  as  the  tumour  has  been 
cut  away,  he  scoops  out  and  disinfects 
the  cervical  canal  in  the  stump.  A  satu- 
rated solution  of  perchloride  of  iron  is 
then  freely  applied  to  the  stump,  the 
superfluous  solution  dried  off,  iodoform 
dusted  over,  and  salicylic  wool  used 
as  dressing.  His  clamp  is  shown  at 
fig.  260. 

The  elastic  ligature  was  introduced  by 
Kleeberg.  Its  method  of  employment 
has  been  devised  and  carried  out  by 
Hegar  of  Freiberg,  in  whose  hands  (as 
already  said)  it  has  produced  good  re- 
sults. Hegar's  method  consists  in  "  con- 
striction of  the  uterine  stump  with 
elastic  ligatures,  exact  closure  of  the 
abdominal  cavity  by  stitching  the  peri- 
toneum round  the  stump,  and  antiseptic 
treatment  of  the  latter  with  the  cautery 
and  chloride  of  zinc." 


Elastic 
Ligature. 


FIG.  260. 


KEITH'S  CLAMP  FOB  SECURING  THE 
PEDICLE  EXTKA-PERITONEALLY. 


The  abdominal  incision  is  always  made  long  enough  to  allow  the  tumour  to  be  pro- 
jected through  it  without  artificial  diminution.  Temporary  sutures  are  placed  along  its 
margins  to  keep  the  peritoneum  in  relation  to  the  skin.  Vascular  adhesions  are  ligatured 
in  two  places  and  divided  between.  The  tumour  is  laid  hold  of  with  a  dry  towel  by  one 
assistant  and  raised  out  of  the  abdomen,  while  another  presses  the  edges  of  the  abdo- 
minal wound  behind  the  advancing  tumour ;  the  greatest  care  is  required  to  hold  the 
tumour  steadily  and  vertically,  as  the  stretched  broad  ligaments  readily  tear — leading  to 
hemorrhage.  The  relations  of  the  bladder  and  the  ovaries  having  been  exactly  ascer- 


438 


AFFECTIONS  OF   UTERUS. 


turned,  the  elastic  ligature  is  placed  round  the  cervix  below  the  seat  of  amputation. 
This  consists  of  a  double  ply  of  india-rubber  ligature  5  millimetres  thick.     While  kept  at 


FIG.  261. 

NEEDLE  FOR  CARRYING  THROUGH  ELASTIC  LIGATURE.  It  consists  of  a  sharp  curved  point,  and  a 
canula  split  halfway  up  the  side.  A  loop  of  the  elastic  ligature,  stretched  till  it  is  thin,  is 
drawn  with  a  thread  into  the  canula,  which  is  then  screwed  into  the  steel  point  (Hegar  und 
Kaltenbach). 

full  stretch  it  is  brought  round  the  uterus  and  firmly  knotted.     Should  this  constriction 
of  the  whole  stump  be  judged  insufficient,  it  is  further  ligatured  in  two  portions  with  the 


FIG.  262. 

TREATMENT  OF  FIBROID  TUMOURS  BY  ELASTIC  LIGATURE  (Hegar  und  KalUnbach). 
a,  Abdominal  incision  with  the  stump  in  its  lower  angle  ;  only  the  peritoneum  is  brought  together 
with  the  lower  sutures,  while  the  upper  sutures  take  in  the  whole  abdominal  wall.     6,  Same  in 
section,  to  show  the  trough  floored  by  the  peritoneum  round  the  stump  and  the  position  of  the 
elastic  ligatures. 


elastic  ligature.     The  needle  represented  at  fig.  261  is  used  to  carry  through  the  stump  a 
double  ligature,  which  is  then  divided  and  tied  round  each  half.     The  tumour  and  uterus 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     439 

are  amputated  above  these  ligatures.  The  peritoneum  is  now  carefully  adapted  round 
the  neck  of  the  stump  beneath  the  elastic  ligature  ;  the  silk  suture,  which  brings  only  the 
edges  of  the  peritoneum  together  in  the  bottom  of  the  wound  just  below  the  pedicle,  is 
looped  into  the  side  of  the  latter  (fig.  262  a)  underneath  the  ligature  (fig.  262  b) :  the 
margins  of  the  peritoneum  above  the  pedicle  are  united  in  a  similar  way  ;  the  next  two 
sutures  of  the  wound  bring  together  only  the  peritoneum,  while  those  further  up  bring 
together  all  the  coats  of  the  abdominal  wall.  Thus  there  is  produced  a  space  which 
surrounds  the  pedicle  and  is  floored  by  the  peritoneum  ;  to  keep  this  space  thoroughly  dry 
and  aseptic,  is  the  aim  of  the  after-treatment.  The  projecting  end  of  the  stump  is 
thoroughly  cauterised;  the  raw  surfaces  round  it  are  painted  with  solution  (3-10  per 
cent. )  of  chloride  of  zinc ;  and  cotton  wadding,  which  has  been  soaked  in  a  2  per  cent, 
solution  of  the  chloride  and  then  thoroughly  dried,  is  packed  round  the  stump.  Finally, 
the  end  of  the  stump  alone  is  touched  with  100  per  cent,  solution.  The  whole  is  covered 
with  protective  silk  and  carbolised  wool,  and  the  antiseptic  dressing  laid  on  so  that  it 
can  be  easily  lifted. 

The  space  round  the  stump  is  kept  thoroughly  dry  by  repeated  dressing  (three  or  four 
times  daily,  according  to  amount  of  discharge)  with  the  chloride  of  zinc  wool ;  the  pedicle 
is  pared  away  gradually  with  scissors  to  diminish  its  size,  to  allow  the  chloride  to  act 
more  thoroughly,  and  to  prevent  pus  from  burrowing.  The  elastic  ligature  is  clipped 
away  about  the  tenth  day.  The  abdominal  wall  is  closed  in  three  parts — the  peritoneum 


FIG.  263. 

MODE  OF  SEWING-U.P  STUMP  IN  EXTRA-PERITONEAL  TREATMENT  OF  PEDICLE  (Fritsck). 

a  vaginal  wall,  aa  os  externum,  6  cervical  canal,  d  c  d  funnel-shaped  raw  surface  left  after  excising 
mucous  membrane,  e  peritoneum,  /  suture. 

with  catgut,  the  aponeurosis  and  muscle  with  silk,  and  the  skin  with  superficial  sutures  ; 
the  lower  angle  of  the  wound  (especially  when  the  walls  are  fatty)  is  drained,  the  tube 
not  passing  into  the  peritoneal  cavity. 

Another  method  of  extra-peritoneal  treatment  of  the  pedicle,  intro- 
duced by  Fritsch,1  does  away  with  clamp  or  permanent  elastic  ligature 
and  uses  stitching  only  to  control  the  vessels — as  in  the  intra-peritoneal 
method. 

After  the  tumour  has  been  brought  out  through  the  incision,  the  upper  portion  of  the 
latter  is  closed.  The  broad  ligaments  are  ligatured  in  two  places  and  divided  between 
the  ligatures,  and  the  elastic  ligature  applied.  After  the  tumour  is  cut  away  the  end  of 
the  stump  is  stitched  as  in  fig.  263.  The  elastic  ligature  is  then  removed ;  and  new 
stitches  put  in  if  there  is  bleeding,  the  uterine  arteries  being  tied  separately  when  visible. 
The  broad-ligament  pedicles  are  drawn  up  and  stitched  to  the  uterine  stump,  round  which 
the  parietal  peritoneum  is  adapted  (fig.  264  a).  The  sutures  to  close  the  abdominal  wound 
are  then  passed,  those  next  the  uterine  stump  being  passed  through  it  (fig.  264  b). 

1  Lot.  clt. 


440  AFFECTIONS  OF  UTERUS. 

He  has  had  noteworthy  success,  having  performed  19  cases  after  this 
method  without  any  deaths. 

A  similar  procedure  has  been  described  by  Kelly, x  with  the  addition 
that  he  passes  a  ligature  horizontally  through  each  side  of  the  cervix  so 
as  to  constrict  the  uterine  arteries. 

The  pedicle  has  also  been  stitched  in  the  abdominal  incision  so  as  to 
be  kept  extra-peritoneal  while  the  abdominal  wall  was  closed  in  over  it 
so  that  it  lay  buried  in  the  muscle.2 

In  the  last  edition  of  this  Manual  we  gave  the  i*esults  of  operations  for 
the  removal  of  fibroids  generally  for  nineteen  of  the  leading  operators, 
which  showed  out  of  a  total  of  590  operations  a  mortality  of  32*3  p.c. 
Such  statistics  which  do  not  discriminate  between  the  different  opera- 
tions for  fibro-myoma  (v.  p.  429)  are  now  felt  to  be  unsatisfactory  ;  to  put 
the  removal  of  a  pediculated  subserous  fibroid  alongside  of  extirpation 


FIG.  264  a.  FIG.  264  b. 

MODE  OK   SUTURING  WALLS  AND   PERITONEUM   ROUND  STUMP  (FritucK). 

a  vagina,  6  cervical  canal,  c  apposed  raw  faces  of  o  abdominal  wound,  6  stump  wound, 

stump,  rf  suture  uniting  parietal  peritoneum  e  to  c  ends  of  broad  ligaments,  e  lower 

stump,  /  suture  closing  raw  surface  of  stump,  g  and  /  upper  skin-suture,  which 

suture  tyingup  broad  ligament,  h  end  of  sutures  d,  keeps  stump  in  position,  g  skin- 

i  surface  of  abdomen,  k  abdominal  wound,  I  stump  sutures,   h   sutures  uniting  peri- 

of  broad  ligaments,  m  their  upper  margin.  toneum  to  stump. 

of  the  greater  portion  of  the  uterus  manifestly  vitiates  statistics.  We 
have  made  the  distinction  wherever  the  material  for  doing  so  was 
furnished  in  the  reports,  but  in  very  many  cases  this  could  not  be  done, 
as  will  be  seen  in  the  following  references  to  the  literature  of  the  last 
three  years  which  deal  with  those  who  have  recorded  ten  operations  and 
upwards. 

Albert    of  Vienna  has  done  12  supra-vaginal  amputations  with  extra-peritoneal  treat- 
ment of  the  pedicle,  and  8  myomotomies,  with  only  1  death  in  the  20  cases. 

Bantock  in  a  recently  reported  series  of  100  cases  of  abdominal  section*  has  15  hysterec- 

1  Amer.  Jour.  Obttet.  1889,  p.  375. 

1  By  von  Hacker  and  Rummel.     F.  N.  Schmidt  (Archivf.  Gyn.  Bd.  XXXIII.,  S.  325)  records  a 
case  treated  successfully  after  this  method. 
3  Centralb.f.  Gyn.  Bd.  XII.,  8.  045.  «  Lancet,  1887,  I.,  p.  518. 


SURGICAL  TREATMENT  OF  FIBROID  TUMOURS.     441 

tomies  with  3  deaths,  or  a  mortality  of  20  p.c.  ;  but  adding  the  9  myomotomies  in  the 
series,  the  mortality  is  reduced  to  12 '5  p.c. 

Braun'  of  Vienna  reports  on  38  cases  of  operation  for  fibroid,  with  6  deaths,  and  is 
strongly  in  favour  of  extra- peritoneal  treatment  of  the  stump  as  both  of  the  cases  treated 
intra-peritoneally  died. 

Fehling2  of  Stuttgart  has  done  10  supra-vaginal  amputations,  with  3  deaths.  Taking 
with  these  his  4  myomotomies,  we  have  out  of  the  14  cases,  11  extra-peritoneal  with  1 
death,  and  3  intra-peritoneal  with  2  deaths. 

Fritsch3  of  Breslau  (if  we  deduct  from  his  sixty -one  operations  those  where  the  uterine 
cavity  was  not  cut  into)  has  had  twenty  intra-peritoneal  with  9  deaths,  and  twenty-seven 
extra-peritoneal  with  3  deaths. 

T.  Keith,  *  now  of  London,  records  26  operations  (one  being  not  for  fibroid  but  for 
sarcoma),  with  4  deaths.  Taking  along  with  these  his  previous  series,  he  has  a  total  of 
04  cases  with  a  mortality  in  hospital  (38  cases)  of  15 '7  p.c.  and  in  private  (26  cases)  of  3'8 
p.c. 

Krassowski5  records  19  cases  of  operation  for  fibroids  with  8  deaths,  viz.  12  extra-peri- 
toneal cases  with  6  deaths,  and  7  intra-peritoneal  with  2  deaths. 

Rein6  of  Kiew  reports  10  cases  of  hysterectomy  (9  treated  intra-peritoneally)  with  2 
deaths. 

Tait7  of  Birmingham,  in  his  second  series  of  1000  abdominal  sections,  mentions  88 
hysterectomies  (including  myomotomies)  with  a  mortality  of  11 '3  p.c. — the  last  31  cases 
being  without  a  death. 

Tauffer  of  Buda-Pesth"  records  16  cases  of  hysterectomy  for  fibroid — 8  extra-peritoneal 
with  2  deaths,  and  8  intra-peritoneal  with  4  deaths. 

Thornton9  of  London  says  he  has  operated  88  times  for  fibro-myoma  with  14  deaths, 
11  being  in  the  first  half  and  only  3  in  the  second  half  of  his  cases. 

Of  cases  by  operators  who  report  no  fewer  than  10  cases  (mostly  isolated  cases)  we  have 
a  total  of  68  operations  with  15  deaths.  Of  these,  33  were  extra-peritoneal  with  7  deaths, 
and  22  intra-peritoneal  with  4  deaths ;  in  13  cases  with  4  deaths,  it  was  not  specified 
whether  the  treatment  was  extra-  or  intra-peritoneal.  These  last  particulars  are  of  little 
value  from  a  statistical  view,  because  the  probability  is  that  isolated  unfavourable  cases 
are  often  not  recorded. 

These  results  show  that  the  mortality  of  operations  for  fibroids  is 
being,  under  improved  methods,  distinctly  reduced.  That  it  will  ever 
be  as  low  as  in  ovariotomy  is  doubtful,  because  these  tumours,  though 
frequent,  only  exceptionally  endanger  life  and  call  for  operation. 

A  fibroid  of  the  cervix  may  push  its  way  into  the  cellular  tissue  and 
displace  the  peritoneum.  Such  an  extra-peritoneal  tumour  may  also  be 
removed  by  laparotomy . *  ° 

ganger ' '  reports  on  two  cases  of  abdominal  section  for  fibroid  tumour  of  the  cervix  :  in 
one,  the  pedicle  was  treated  by  the  elastic  ligature  and  dropped  back  ;  in  the  other,  the 
uterus  was  amputated  and  the  stump  stitched  by  Zweifel's  method  (see  p.  434)  and 
dropped  back.  Kelly  * 2  also  cut  down  on  two  fibroid  tumours  of  the  cervix  and  removed 
them  with  ecraseur ;  no  pedicle  was  tied,  but  the  peritoneal  cavity  was  drained  and 
washed  out  for  some  days  afterward.  By  ford  13  has  removed  a  subserous  fibroid  of  the 
cervix  per  vaginam. 


1  Brit.  Med.  Journ.,  1888,  I.,  p.  211.  2  Centralb.f.  Gyn.,  Bd.  XI.,  S.  276. 

»  Loc.  cit.  *  Brit.  Med.  Jour.,  1887,  II.,  p.  1257. 

8  Centralb.f.  Gyn.,  Bd.  XII.,  S.  199.  "  Centralb.f.  Gyn.,  Bd.  XII.,  S.  852. 

'  Brit.  Med.  Join:  188S,  II.,  p.  1096.  He  attributes  the  diminution  in  his  mortality  (which  was 
35-7  p.c.  in  his  former  series  of  1000  oases)  to  tying  the  broad  ligaments  so  as  to  strip  them  off  the 
uterus  before  its  amputation. 

«  Centralb.  f.  Gyn.  Bd.  XII.,  S.  123.  9  Lancet,  1S86,  II.,  p.  212. 

10  As  in  Thelen's'case  :  Centralb.  f.Gyn.,  18S5,  No.  3.       "  Centralb.  f.  Gyn.,  Bd.  XIII.,  S.  207. 
12  Amer.  Jour.  Obstet.,  1886,  p.  45.  13  Amer.  Jour.  Obttet.,  1888,  1205. 


442  AFFECTIONS  OF  UTERUS. 


C.     REMOVAL    OP   OVARIES    OR    OF   UTERINE   APPENDAGES. 

The  removal  of  these,  as  we  have  seen  (v.  p.  209),  usually  stops  men- 
struation and  induces  the  menopause.  Hence  in  the  case  of  fibroid 
tumours  this  operation  does  good  in  two  ways — by  checking  bleeding 
and  stopping  the  growth  of  the  tumour.  The  mortality  is  also  low 
(under  3  p.c.),  so  that  this  operation,  were  it  always  practicable,  would 
have  a  wide  field  in  the  treatment  of  myoma.  Unfortunately,  it  is 
frequently  impossible  to  get  at  both  ovaries  in  cases  of  large  myoma ; 
•while  one  is  to  the  front  and  easily  accessible,  the  other  is  to  the 
back  and  sometimes  low  down  towards  the  pouch  of  Douglas.  The 
technique  is  the  same  as  that  described  in  Chapter  XXL,  with  the  excep- 
tion that  a  long  abdominal  incision  is  often  necessary  to  allow  the 
operator  to  pass  the  whole  hand  into  the  abdomen  so  as  to  get  at  the 
appendages.  As  to  the  mortality,  the  largest  series  recently  published 
is  by  Lawson  Tait,  who  had  in  148  cases  only  3  deaths.  The  other 
cases  (37)  which  we  have  collected  from  the  literature  show  a  mortality 
of  5'4  p.c. 

SUMMARY   AS    TO    OPERATIVE   TREATMENT    OP    FIBROID    TUMOURS. 

We  may  sum  up  the  question  of  the  treatment  of  fibroids,  so  far  as  it 
is  known  at  present,  as  follows  : — 

(1.)  When  polypoid,  or  submucous  and  being  expelled,  treat  as  recom- 
mended in  Chap.  XXXIX. 

(2.)  When  subperitoneal,  if  causing  no  inconvenience,  though  large, 
leave  them  alone. 

(3.)  When  growing  rapidly  or  threatening  life  from  haemorrhage,  and 
where  the  patient  is  not  near  the  menopause,  we  may  operate. 

(a.)  We  may  remove  the  uterine  appendages  if  they  are  accessible. 
It  should  be  kept  in  mind  that  it  is  sometimes  very  difficult,  or  even 
impossible,  to  do  so. 

(6.)  Abdominal  section  and  extra-peritoneal  treatment  of  the  pedicle 
by  clamp  or  serre-nceud  or  stitching  gives  the  best  results. 


CHAPTER    XXXVIII. 

FIBRO-CYSTIC  TUMOUR  OF  THE  UTERUS. 

LITERATURE. 

Alice — Ovarian  Tumours  :  Philadelphia,  1873.  Beates — Cystic  leiomyoma  of  Uterus  : 
Am.  Journ.  of  Ohstet.,  1884,  p.  753.  De  Sindty — Manuel  de  Gynecologic,  Paris, 
1879,  p.  413.  Diesterweg — Ein  Fall  von  cysto-fibroma  verum  :  Zts.  f .  Geb.  und  Gyn. 
IX.,  S.  191.  Grasskopff—Zur  Kentniss  der  Cystomyome  des  Uterus  :  Munich,  1884. 
Gusserow — Neubildungen,  etc.  :  Stuttgart,  1885,  S.  117.  Heer — Ueber  Fibrocysten 
des  Uterus :  Zurich,  1874.  Leopold  and  Fehling — Ein  Beitrag  zur  Lehre  von  den 
kystischen  Myomen  des  Uterus  (Myosarcoma  lymphangiektodes  uteri) :  Archiv  fur 
Gyn. ,  Bd.  VII. ,  S.  531 .  Peaslee — Ovarian  Tumours :  London,  1873.  Rein — Beitrag 
zur  Lehre  von  den  lymphangiectatischen  Fibromyomen  des  Uterus  in  pathologisch- 
anatomischer  und  klinischer  Beziehung  :  Archiv  f.  Gyn.,  IX.,  S.  414.  Schroeder — 
Die  Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  213 :  Leipzig,  1878.  Sir 
Spencer  Welh — Ovarian  and  Uterine  Tumours :  London,  1883.  Spiegelberg — Die 
Diagnose  der  cystischen  Myome  des  Uterus  und  ihre  intraperitoneale  Ausschalung, 
eine  neue  Operationsmethode  derselben :  Archiv  f.  Gyn.,  VI.,  S.  341.  Thomas — 
Diseases  of  Women,  p.  551 :  London,  1882. 

SYNONYM — Cysto-fibroma. 

Attention  has  been  directed  only  of  recent  years  to  this,  the  rarest 
form  of  uterine  tumour.  Its  pathology  is  now  being  worked  out,  and  at 
present  we  group  under  this  head  tumours  which  may  afterwards  be 
shown  to  be  anatomically  separable.  Since  ovariotomy  has  come  to  be 
extensively  practised,  they  have  derived  clinical  importance  from  their 
close  resemblance  to  ovarian  tumours. 

PATHOLOGY. 

The  majority  of  fibro-cystic  tumours  are  simply  fibroid  tumours  which 
have  become  softened.  The  spaces  between  the  bundles  of  fibrous  tissue 
open  out  and  contain  serum ;  the  trabeculse  between  adjoining  spaces 
give  way,  which  allows  these  to  run  together  to  form  larger  cavities. 
Fig.  265  shows  this  in  a  subserous  fibroid,  which  form  most  frequently 
undergoes  this  change. 

The  term  "cystic,"  is,  it  is  evident,  misleading  as  applied  to  this 
form  of  tumour.  The  cavities  are  not  "cysts,"  that  is,  they  do  not 
possess  a  special  wall. 

Kceberle  was  the  first  to  suggest  that  some  forms  of  fibro-cystic  tumour  Lymphatic 
might  be  due  to  dilated  lymphatics.     Leopold  and  Fehling  have  care-ongin- 


444 


AFFECTIONS  OF   UTERUS. 


fully  described  a  case  in  which  the  cavities  were  lined  with  endothelium. 
The  fluid  from  these  cavities  was  of  a  clear  yellow  colour,  and  coagulated 
as  soon  as  it  was  exposed  to  the  air ;  fibrin  was  present  in  it.  To  this 
form  the  name  of  Fibromyoma  lymphangiektod.es  has  been  given. 
Mtiller1  has  also  described  recently  a  preparation  in  which  he  found  the 
epithelial  lining  present  in  the  smaller  cysts.  Atlee  says  this  coagula- 
tion of  the  fluid — formation  of  colourless  blood-clot — is  diagnostic  of 
the  fluid  from  all  fibro-cystic  tumours,  and  may  be  relied  on  to 


FIG.  265. 

LARGE  THREE-LOBED  FIBROID  SPRINGING  FROM  THE  FUNDUS  BY  A  SOMEWHAT  THIN  PEDICLE,  of 
which  CF  is  cystic,  while  SsF  and  the  dark  shaded  mass  behind  the  uterus  are  subserous.  This 
along  with  two  smaller  fibroids  growing  from  the  posterior  surface  of  the  uterus  was  removed 
by  Laparotomy  (Schroeder). 

distinguish  them  from  ovarian.  Spiegelberg  records  a  case  in  which 
this  spontaneous  coagulation  of  the  fluid  was  observed,  but  the  most 
careful  microscopic  examination  could  detect  no  epithelial  lining  of 

1  Beitrag  zur  kenntniss  der  cystoiden  Uterustumoren  :  Archivf.  Gyn.,  Bd.  XXX.,  S.  249. 


FIB RO-CY STIC   TUMOURS.  445 

the  cavities.  A  transition  case  has  been  described  by  Rein,  in  which 
the  cavities  were  not  themselves  lined  with  endothelium  but  communi- 
cated directly  with  the  lymphatic  spaces. 

Mucoid  degeneration   of  a  fibroid   tumour   has   been   described   byMucoid 
Virchow  as  Myxomyoma.     In  this  case  the  interstitial  tissue  contained  J?egenera" 
fluid  rich  in  mucin  and  with  numerous  nucleated  round  cells. 

Sarcomatous  degeneration  of  a  fibroid1  apparently  also  produces  a 
cystic  condition  of  a  fibroid  tumour  although  this  is  not  a  true  fibro- 
cystic  tumour. 

Cysts  with  an  epithelial  lining  have  been  described  by  Babesin  and 
Diesterweg.  The  latter  removed  on  two  occasions  (with  two  years' 
interval)  a  submucous  polypus  with  cysts ;  the  cavities  were  lined  with 
ciliated  epithelium  and  contained  thin  brownish  blood.  Baer  on  cutting 
through  a  similar  polypus  with  the  ecraseur  was  afraid  that  he  had 
cut  through  the  peritoneal  cup  of  an  inverted  uterus,  as  the  appearance 
of  the  section  of  the  cyst  resembled  it. 

SYMPTOMS. 

These  are  the  same  as  those  of  fibroid  tumours,  except  that  their 
increase  in  size  is  rapid.  As  they  are  usually  subserous,  menorrhagia 
is  not  often  present. 

DIAGNOSIS;  DIFFERENTIAL  DIAGNOSIS. 

Their  diagnosis  is  often  difficult,  as  the  difference  in  consistence 
between  the  more  solid  and  the  fluid  parts  may  escape  detection.  The 
most  important  point  to  make  out  is  the  relation  to  the  uterus,  and  the 
displacement  of  the  latter  which  is  produced.  To  ascertain  its  connec- 
tion with  the  uterus,  we  make  the  examination  per  rectum :  to  do  this 
thoroughly,  it  may  be  necessary  to  anaesthetise  the  patient  and  to  intro- 
duce two  fingers ;  the  uterus  is  at  the  same  time  drawn  down  with  the 
volsella.  As  to  the  displacement  of  the  uterus,  it  is  elevated  towards 
the  abdomen ;  with  an  ovarian  tumour,  it  is  depressed  to  the  front  or  to 
the  back.  The  sound  is  now  passed ;  if  the  uterine  cavity  is  increased 
in  size,  and  more  especially  if  the  movement  of  the  tumour  by  an 
assistant  is  immediately  communicated  to  the  sound,  the  tumour  is 
probably  uterine. 

Differential  Diagnosis. — Their  diagnosis  from  ovarian  tumours  is  the 
most  important  and,  at  the  same  time,  the  most  difficult.  As  in  the 
majority  of  cases  they  are  merely  altered  fibroid  tumours,  their  differ- 
entiation from  a  simple  fibroid  is  merely  a  matter  of  degree  of  softness. 
In  a  case  described  by  Beates  as  one  of  Cystic  Leio-myoma  of  the  uterus, 
the  patient  had  been  tapped  twice ;  and  as  the  fluid  gave  the  ovarian 

1  As  in  Fenger's  case  (A»wr.  Jour.  Obstet.,  1888,  p.  1200),  and  probably  also  Erich's  (ibid.  1886, 
p.  517). 


446  AFFECTIONS  OF  UTERUS. 

cell  described  by  Drysdale  (v.  p.  222),  the  case  was  set  down  as 
undoubtedly  one  of  ovarian  tumours.  The  differential  diagnosis  from 
ovarian  tumour  is  often  not  made  till  the  abdomen  is  opened. 

TREATMENT. 

The  treatment  consists  in  removal  through  the  abdominal  walls, 
according  to  the  method  described  for  fibroid  tumours  (v.  p.  430). 
References  to  recent  cases  of  Laparotomy  for  Fibro-cystic  tumours  by 
Boldt,  Byford,  Dawson,  Harsha,  Marta,  Morris,  Miiller,  Negri,  O'Hara, 
Plimmor,  Swiecicki,  Lawson  Tait,  Walter,  Wilson,  and  Wylie,  will  be 
found  in  the  Index  of  Recent  Gynecological  Literature. 

Morris'1  case  has  this  special  interest  that  it  was  a  second  case  of 
operation,  a  fibro-cystic  tumour  having  been  removed  from  the  same 
uterus  eight  years  previously. 

1  Lancet,  1888, 1.,  973. 


CHAPTER  XXXIX. 

POLYPI  OF  THE  UTERUS. 

LITERA  TDRS. 

Barnes — Diseases  of  Women,  p.  195 :  London,  1878.  De  Sinety — Manuel  pratique  de 
Gynecologic,  p.  419 :  Paris,  1879.  Gusserow — Die  Neubildungen  des  Uterus,  Bill- 
roth's  Handbuch,  S.  179  :  Stuttgart,  1885.  Hegar  und  Kalteribach — Die  operative 
Gynakologie,  S.  473  :  Stuttgart,  1881.  Hicks,  Braxton — Three  cases  of  very  large 
polypi  of  the  uterus,  etc. :  Obstet.  Journ.  of  Great  Brit.,  Jan.  1879.  Kustner — 
Notiz  zur  Metamorphose  des  Utemsepithels :  Centralblatt  f.  Gyn.  1884,  p.  321. 
Matthews  Duncan — Edin.  Med.  Journ.  July  1871 ;  and  Obstet.  Journ.  1873,  p.  497. 
Simpson,  Sir  J.  Y. — Diseases  of  Women,  p.  704 :  Edin.  1872.  Thomas — Diseases 
of  Women :  London,  1880,  p.  558.  Underhill — On  the  Structure  of  three  cervical 
Polypi,  and  the  Structure  of  a  true  mucous  Polypus  of  the  Cervix  :  Edin.  Obst.  Soc. 
Trans.,  Vol.  IV.,  pp.  231  and  241. 

BY  the  term  "  Polypus "  is  understood  a  pediculated  tumour  attached 
to  the  mucous  membrane  of  the  uterus.  It  includes  the  following 
tumours,  which  are  anatomically  distinct : — 

1.  Submucous  fibroids,  which  have  become  pediculated  and  are  in 

process  of  extrusion ; 

2.  Mucous  polypi  and  adenoma  ; 

3.  Pediculated  cystic  follicles ; 

4.  Placental  polypi ; 

5.  Papilloma  of  the  cervix. 

For  clinical  reasons,  it  is  convenient  to  use  the  term  polypus  in  its 
general  sense  as  implying  an  external  form  alone ;  the  symptoms  pro- 
duced by  these  tumours  resemble  one  another,  and  their  exact  nature 
is  sometimes  not  made  out  till  they  are  removed.  Pathologically,  the 
term  should  be  limited  to  mucous  polypi.  It  is  confusing  to  speak  of 
a  fibroid  tumour  which  has  a  broad  base  of  attachment  as  a  submucous 
fibroid,  and  of  one  which  has  a  pedicle  as  a  fibrous  polypus.  The  poly- 
poidal  projections  formed  by  pediculated  ovula  Nabothii  are  only  pedi- 
culated retention  cysts.  Placental  polypi  are  not  true  new-formations. 

1.  Pediculated  submucous  fibroid  tumours  form  the  so-called  "  fibrous  Pedicu- 
polypi."     They  spring  from  the  muscular  wall  of  the  uterus,  usually late(*  Sul)" 
from  the  body  which,  as  we  have  seen,  is  more  commonly  the  seat  of  Fibroids, 
fibroid  tumours  than  the  cervix.     They  are  oifirm  consistence,  of  a  size 
varying  from  a  goose's  egg  and  upwards,  and  are  of  a  rounded  or  pyriform 
shape  (fig.  266),  sometimes  elongated  and  constricted  through  the  pressure 


448 


AFFECTIONS   OF   UTERUS. 


of  the  uterine  walls  (fig.   248) ;  the  surface  is  smooth  or  marked  with 
furrows  corresponding  to  the  fasciculi  of  fibrous  tissue. 

Sometimes  they  are  of  such  a  size  *  that,  although  lying  in  the  vagina, 
they  fill  the  pelvis  and  press  on  the  bladder  and  rectum ;  the  uterus  is 
then  raised  above  the  pelvic  brim  (just  as  it  is  elevated  when  the  vagina 
is  distended  with  fluid),  and  is  felt  as  a  smaller  body  riding  on  the  top 
of  the  tumour.  Adhesions  may  form  between  the  surface  of  the  fibroid 
and  the  vagina,  producing  the  impression  that  the  tumour  springs  from 
the  vaginal  mucous  membrane.2 


FIG.  266. 

FIBROUS  POLYPUS  LAID  OPEN  TO  SHOW  ITS  IDENTITY  IN  STRUCTURE  WITH  A  FIBROID  TUMOUR 
(Sir  J.  Y.  Simpson). 

The  pedicle  consists  of  a  narrowing  of  the  calibre  of  the  tumour 
towards  its  base  of  attachment,  or  of  a  distinct  stalk  which  may  be  long 
enough  to  allow  the  fibroid  to  lie  at  the  vulva.  As  fibroid  tumours  are 
sparingly  vascular,  the  pedicle  does  not  as  a  rule  contain  large  vessels. 
When  a  pediculated  submucous  fibroid  lies  in  the  cavity  of  the  uterus, 
it  sets  up  uterine  contractions  which  lead  to  its  expulsion ;  there  is  a 

1  Koeberle  removed  one  weighing  over  1J  Ibs.  (Centralb.f.  Gyn.  1889,  S.  263). 
1  Braxton  Hicks — Loc.  cit. 


POLYPI. 


449 


stage  at  which  it  lies  partly  within  the  uterus  (fig.  267),  partly  in  the 
vagina  (the  portion  constricted  by  the  cervix  has  been  mistaken  for  a 
pedicle,  and  only  the  lower  lobe  of  the  hour-glass  tumour  removed) ; 
finally,  the  whole  tumour  lies  in  the  vagina  but  still  maintains  its  con- 
nection with  the  uterus  through  its  pedicle  (fig.  268).  The  congestion  of 
the  fibroid  excites  uterine  contractions,  specially  at  the  menstrual  period, 


FIG.  267. 

INTRA-UTERIXE  SUBMUCOUS  FIBROID  WHICH  is  BECOMING  VAGINAL  (Sir  J.  T.  Simpson). 

and  thus  favours  its  expulsion.  At  those  times  only,  we  may  have  the 
cervical  canal  temporarily  dilated  and  the  polypus  projecting  through  it; 
after  the  period,  the  contractions  pass  off  and  the  polypus  is  retracted 
into  the  uterine  cavity.  This  condition  is  fully  described  by  French 
writers  under  the  name  of  "polypes  a  apparations  intermittentes."  Its 
practical  importance  is  that  we  should  examine  sometimes  at  the  men- 
2P 


450 


AFFECTIONS  OF   UTERUS. 


Mucous 
Polypi. 


strual  period,  when  a  polypus  (not  recognisable  at  other  times)  may  be 
felt  through  a  dilated  cervix. 

They  have  the  microscopic  structure  described  at  p.  404  (v.  fig.  266). 

2.  Mucous  polypi  are  developed  from  the  mucous  membrane  of  the 
uterus,  most  frequently  from  that  of  the  cervix.  They  are  of  soft  pulpy 
consistence,  of  about  the  size  of  an  almond — rarely  larger — and  have  a 
flattened  form;  usually,  there  are  more  than  one  present  (fig.  269).  They 
are  extremely  vascular  and  have  the  microscopic  structure  of  the  mucous 
membrane  from  which  they  are  developed. 

The  typical  cervical  polypus  has  the  structure  seen  at  fig.  270 ;  the 
student  should  compare  this  with  the  section  of  the  normal  mucous 
membrane  given  at  p.  20.  From  the  fact  that  the  gland-ducts  appear  as 


FIG.  268. 
SUBMUCOUS  FIBROID  WHICH  HAS  COME  TO  LIE  WHOLLY  IN  THE  VAGINA  (Sir  J.  Y.  Simpson) 

channels  on  the  surface,  it  was  described  by  Oldham  as  the  "  channelled 
polypus."  Sometimes  the  polypus  shows  also  the  stratified  epithelium  of 
the  vaginal  aspect  of  the  cervix,  as  in  a  specimen  described  by  Underbill ; 
he  supposes  that  in  this  case  it  sprang  from  the  margin  of  the  os  exter- 
num :  he  describes  also  a  polypus  which  sprang  from  the  vaginal  aspect 
and  showed  only  the  stratified  epithelium.  Kustner  has  shown  that 
stratified  epithelium  may  be  found  on  mucous  polypi  which  have  grown 
high  up  in  the  cervical  canal ;  this  is  another  example  of  how  the  single- 
layered  uterine  epithelium  may  become  changed  into  stratified  epithelium 
(cf.  Zeller's  Observations,  p.  318).  These  polypi  sometimes  form  the 


POLYPI. 


451 


starting-point  of  malignant  disease  ;  Underbill  traced  the  commencement 
of  sarcomatous  formation  in  one  case. 


FIG.  269. 

GROUP  OF  Mucous  POLYPI  GROWING  IN  THE  CERVIX  UTERI  (Sir  J.  Y.  Simpson). 

De  Sinety  divides  them  into  two  groups  according  as  they  spring  (1) 
from  the   cervix,   (2)  from   the   body   of  the  uterus.     Each   has  the 


FIG.  270. 

SECTION  OF  A  Mucous  POLYPUS  OF  THE  CERVIX  *f-.    g  dilated  glands,  e  epithelium,  mf  muscular 
fibre,  v  blood- vessel,  ct  connective  tissue  (De  Sinety). 

characteristic  epithelium  (see  p.   19)  lining  the  ducts  and  cysts;   the 


452  AFFECTIONS  OF  UTERUS. 

former  have  the  columnar  non-ciliated  epithelium  of  the  cervix,  the  latter 
the  ciliated  cylindrical  epithelium  of  the  body. 

A  localised  hypertrophy  of  the  glands  of  the  uterus  has  been  described 
by  Schroeder  as  adenoma  polyposum;  the  changes  resemble  those  of 
glandular  endometritis  (v.  p.  316). 

Williams,  in  his  recent  monograph, 1  describes  four  cases  of  adenoma  of 
the  cervix,  two  being  simple  villous  growths  and  two  being  malignant. 

3.  Pediculated  Nabothian  follicles  have  been  already  described  under 
cervical  catarrh  (p.  306). 

Placental        4.  Placenta!  or  fibrinous  polypi.     These  are  produced  as  the  result  of 

Polypi.       incomplete  detachment  of  the  placenta;   in  some  cases  we  can  trace 

placental  villi  in  their  structure.     On  the  surface  of  this  irregularity  of 

the  mucous  membrane,  blood  coagulates;   and  thus  the  fragment  of 


FIG.  271. 
NON-MALIGNANT  PAPILLOMA  OR  FIBROMA  PAPILLARK  or  CEKVIX  (Actermtmri)* 

placenta  grows  larger  through  being  coated  with  fibrin.  This  increase 
in  size  may  go  on  until  the  polypus  is  the  size  of  an  egg.  This  form  of 
polypus  is  not  a  new  formation  and  only  finds  a  place  here  on 
account  of  its  polypoidal  form.  When  it  sets  up  a  foetid  discharge 
and  the  patient  becomes  cachectic,  it  may  simulate  malignant  disease 
of  the  uterus. 2  After  an  abortion, 3  they  may  form  in  the  same  way  :  a 
piece  of  decidua  left  in  the  uterus  maintains  its  structure  and  vitality 
and  nutritive  connection  with  the  tissues  below. 

5.  Papilloma  of  the  cervix.     Simple  papilloma  of  the  cervix  is  a  very 
rare  form  of  tumour ;  the  great  proportion  of  papillary  tumours  found 

1  Cancer  of  the  Uterus :  London,  1888,  pp.  40-44. 

a  As  in  the  case  reported  by  Baer :  Am.  Journ.  of  Obstet.  1885,  192. 

*  Kiistner — Beitrage  zur  Lehre  Ton  der  Endometritis :  Jena,  1883. 


POLYPI.  453 

here  are  malignant  (carcinomatous  or  sarcomatous).  Fig.  271  shows 
such  a  tumour,  described  by  Ackermann,1  which  sprang  from  the 
anterior  lip  of  the  cervix.  It  consisted  of  a  branching  stem  of  connec- 
tive tissue,  with  papillae  covered  mostly  with  squamous  but  in  some 
places  with  a  single  layer  of  cylindrical  epithelium.  There  was  no 
recurrence  after  removal.  The  term  "cauliflower"  excrescence,  intro- 
duced by  Clarke,  describes  very  well  the  appearance  of  these  tumours. 
Virchow  has  shown  that  in  many  of  these  papillomata  we  find  proliferation 
of  the  epithelium,  and  that  they  form  the  first  stage  of  epithelial  cancer 
of  the  cervix  (v.  p.  464) ;  we  must  therefore  regard  the  cauliflower 
excrescence  as,  in  the  great  proportion  of  cases,  a  malignant  tumour. 

SYMPTOMS. 

These  are  Haemorrhage, 
Leucorrhoea, 
Dysmenorrhoeal  pains, 
Sterility, 
Irritation  and  discomfort. 

The  haemorrhage  shows  itself  first  as  an  increase  of  the  ordinary  men-Hsemor- 
strual  flow ;  afterwards,  it  comes  at  irregular  intervals.  In  the  case  of  a 
submucous  fibroid,  it  comes  from  the  uterine  mucous  membrane  which 
is  hypertrophied.  In  the  mucous  polypus,  it  comes  from  the  tumour 
itself  which  is  vascular  and  bleeds  easily ;  when  the  polypus  protrudes 
through  the  cervix,  there'  may  be  haemorrhage2  (v.  the  preparation 
represented  at  fig.  94).  In  other  cases  the  drain  of  blood,  though  not 
directly  fatal,  may  produce  profound  anaemia ;  hence  the  importance  of 
ascertaining  and  removing  the  cause  of  the  haemorrhage.  The  cachectic 
appearance  of  the  patient,  thus  induced,  may  be  such  as  to  lead  us  to 
form  a  strong  prepossession  in  favour  of  the  existence  of  malignant  disease 
before  we  proceed  to  physical  examination. 

The  leucorrhosa  is  due  to  the  endometritis  which  is  always  present.  Leucor- 
The  polypoidal  retention  cysts  are  the  result  of  a  chronic  catarrh  of  the  r 
cervix  or  uterus.     It  is  disputed  whether  mucous  polypi  are  the  cause  or 
the  result  of  the  inflammatory  changes ;  De  Sinety  inclines  to  the  latter 
view.     When  the  polypus  comes  to  lie  in  the  vagina,  it  produces  an 
irritating  vaginal  leucorrhrea. 

The  dysmenorrhoeal  pains  are  due  to  the  muscular  efforts  of  the  uterus  Dysmen- 
to   expel  the   polypus,  and   are   most  marked  when  the   polypus  haspains 
descended  to  the  os  internum  or  lies  in  the  cervical  canal. 

In  rare  cases  the  presence  of  the  foreign  body  in  the  uterus  has 
produced  the  sympathetic  phenomena  of  pregnancy — pigmentation  of  the 
breasts  and  abdomen  and  morning  sickness. 

1  Virclww'sArchiv:  Bd.  XLI1I.  S.  88. 

2  Barnes  records  the  case  of  a  woman  of  twenty-six  years  of  age  in   which  a  polypus  the 
size  of  a  walnut  produced  a  fatal  haemorrhage. 


454 


AFFECTIONS  OF  UTERUS. 


Sterility.  Sterility  is  occasioned  by  the  mechanical  obstruction  of  the  polypus, 
either  in  the  cervical  canal  or  at  the  entrance  to  the  Fallopian  tubes. 
The  obstruction  in  one  case  was  not  sufficient  to  prevent  the  spermatozoa 
from  passing  upwards,  but  hindered  the  entrance  of  the  fertilised  ovum 
into  the  uterine  cavity  and  thus  produced  Fallopian-tube  gestation. 

A  pediculated  fibroid  may  form  a  serious  complication  to  labour,  in 
preventing  the  progress  of  the  child's  head  ;  such  a  polypus  has  been  laid 
hold  of  with  the  forceps  under  the  impression  that  it  was  the  presenting 
head.  They  may  also  give  rise  to  haemorrhage  in  the  puerperium. x 


FIG.  272. 

PEDICULATED  SUBMUCOUS  FIBROID,  springing  from  the  fundus,  which  has  not  dilated  the  cervical 
canal  (Sir  J.  Y.  Simpson). 

DIAGNOSIS. 

1.  When  the  polypus  has  dilated  the  os  externum,  it  will  be  recognised 
by  the  finger  per  vaginam.  If  it  be  larger  than  a  walnut  and  of  firm 
consistence,  and  if  the  uterine  cavity  be  increased  in  length,  it  is  a 

1  See  paper  by  Halliday  Crooni  on  Fibrous  Polypi  complicating  the  puerperiiim  :  Edin.  Med.  Journ. 
XXXII.  I.,  p.  289. 


POLYPI.  455 

pediculated  fibroid  tumour.  If  it  be  small  and  of  a  pulpy  consistence,  it 
is  a  true  mucous  polypus ;  mucous  polypi  do  not,  as  a  rule,  produce 
hypertrophy  of  the  uterus. 

Having  learned  that  there  is  a  pediculated  body  in  the  vagina  or 
cervical  canal,  carry  the  finger  upwards  to  ascertain  its  point  of  attach- 
ment ;  if  this  be  high  up  in  the  uterine  cavity  the  tumour  is  a  pedicu- 
lated fibroid;  if  it  springs  from  the  cervical  mucous  membrane,  it  is 
probably  a  mucous  polypus. 

On  bimauual  examination,  the  uterus  is  found  to  be  enlarged  in  the 
case  of  pediculated  fibroids;  it  is  not  enlarged  with  mucous  polypi, 
unless  from  associated  chronic  metritis. 

The  speculum  shows  that  the  surface  of  the  true  mucous  polypus  has 
a  bright  cherry-red  colour,  which  contrasts  with  the  darker  red  of  the 
cervical  mucous  membrane  embracing  it.  The  appearance  of  the  fibroid 
tumour  depends  on  the  condition  of  the  investing  mucous  membrane 
which  is  often  ulcerated  or  sloughing ;  when  the  capsule  has  given 
way,  the  fibrous  substance  of  the  tumour  is  seen  to  be  of  a  paler 
colour. 

2.  When  the  uterus  is  enlarged  but  the  os  externum  not  dilated,  the 
diagnosis  is  more  difficult  (fig.  272).     If  the  uterus  be  markedly  enlarged 
and  of  firm  consistence  and  (the  possibility  of  pregnancy  being  excluded) 
the  sound  pass  for  4  or  5  inches,  there  is  probably  a  submucous  fibroid 
tumour.     It  is  difficult  to  determine  whether  it  is  pediculated  or  not. 
We  endeavour  first  to  pass  the  sound  round  the  tumour  or  upwards  on 
different  sides  of  it.     Fig.  253  shows  how  the  sound  passes  in  a  case  of 
a  pediculated  tumour  attached  to  the  fundus.     The  sound    must   be 
used  with  care  as  its  use  is  not  unattended  with  risk ;  laceration  of  the 
mucous  membrane,  with  the  introduction  of  septic  matter,  has  resulted 
from  too  free  and  repeated  exploration  in  this  way.     Dilatation  of  the 
cervix   and   exploration  with   the   finger   are   sometimes   necessary  to 
ascertain  whether  the  fibroid  be  pediculated  and  to  what  part  of  the 
uterus  it  is  attached. 

3.  When   the   uterus   is   not   much   enlarged,    the    diagnosis    is   very 
difficult.      The  possibility  of  a  fibroid  tumour  is  excluded.     A  small 
mucous    polypus,    however,    may    exist    in    the    uterine    cavity    and 
escape  detection  with   the  sound.      In  such  a  case,  it   is   recognised 
only  on   dilating   the   cervix  and   exploring  the   uterine   cavity   with 
the  finger. 

The  curette  is  a  valuable  aid  to  diagnosis  when  the  actual  exploration 
of  the  uterine  cavity  with  the  finger  is  not  desirable.  By  its  use  we 
diagnose  and  treat  the  case  at  the  same  time.  Thus  irregularity  of  the 
uterine  surface  (which  is  easily  detected  by  the  curette)  and  the 
character  of  the  scrapings  removed,  may  show  that  we  have  to  do  with 
pediculated  retention  cysts  or  placental  polypi. 


456 


AFFECTIONS  OF  UTERUS. 


DIFFERENTIAL    DIAGNOSIS. 

The  characters  which  distinguish  a  pediculated  fibroid  from  a  mucous 
polypus  are  its  larger  size,  firmer  consistence,  and  its  springing  from  the 
body  of  the  uterus.  The  uterine  cavity  is  increased  in  size.  We  probably 
find,  also,  other  fibroid  tumours  interstitial  or  subserous. 

A  pediculated  fibroid  hanging  down  into  the  vagina,  may  readily  be 
mistaken  for  the  inverted  fundus  uteri ;  this  is  most  likely  to  happen 


FIG.  273. 

o,  Uterus  with  a  portion  of  the  anterior  wall  cut  out ;  6,  pediculated  fibroid  attached  to  back  wall 
immediately  above  os  internum.  The  front  of  the  bony  pelvis  has  been  removed ;  cc,  halves 
of  divided  bladder  (A.  R.  Simpson). 

when  there  is  much  haemorrhage  from  the  former,  and  when  concomi- 
tant pelvic  inflammation  makes  examination  difficult.  A  true  diagnosis 
here  is  all-important,  as  removal  of  the  fibroid  may  save  the  patient's 
life ;  while  amputation  of  the  uterus,  under  the  supposition  that  it  was 
a  fibroid,  might  lead  to  disastrous  consequences.  The  preparation  shown 
at  fig.  273  is  interesting  in  this  connection.  The  case  had  been  sent 
into  hospital  as  one  of  inverted  uterus.  It  is  evident  how  the  form  of 


POLYPI.  457 

the  tumour  in  the  vagina  and  the  fact  that  it  bled  freely,  would  in  the 
absence  of  further  examination  lead  to  this  mistake. 

Given  a  tumour  the  size  of  a  pear  hanging  down  through  the  cervical 
canal  into  the  vagina,  we  wish  to  make  sure  that  it  is  not  the  inverted 
body.  First,  sweep  the  finger  carefully  round  the  neck  and  note 
whether  the  mucous  membrane  of  the  cervical  canal  is  reflected  on  to 
the  neck  of  the  tumour ;  sometimes  inflammatory  adhesions  round  the 
neck  produce  a  condition  simulating  inversion.  Now  make  the 
Bimanual ;  if  the  body  in  the  vagina  be  a  fibroid,  the  uterus  will  be  in 
its  normal  place.  The  abdomino-vaginal  examination  is  often  difficult  on 
account  of  the  body  in  the  vagina ;  therefore  pass  the  finger  into  the 
rectum,  through  the  anterior  wall  of  which  we  can  distinctly  feel 
whether  the  cervix  has  a  truncated  end  above  (inversion)  or  passes  up 
into  the  body  of  the  uterus  (fibroid) ;  the  abdomino-rectal  makes  this 
more  evident.  When  examination  is  difficult  and  the  diagnosis 
doubtful,  we  should  not  hesitate  to  give  chloroform  and  make  a 
thorough  examination;  it  is  well  to  be  prepared  to  operate  at  the 
same  time,  if  necessary. 

Finally  use  the  sound,  which  is  an  important  test.  Sweep  the  finger 
carefully  round  the  neck  of  the  tumour  and  feel  for  a  depression  cor- 
responding to  the  os,  into  which  endeavour  to  introduce  the  sound.  If  it 
passes  for  two  and  a  half  inches  or  more  and  is  then  arrested,  it  is 
probably  in  the  uterine  cavity  ;  make  sure  of  this  by  pressure  with  the 
hand  on  the  abdomimal  wall,  or  per  rectum. 

When  the  tumour  in  the  vagina  fills  the  pelvis  or  rides  above  the 
brim,  so  that  the  finger  cannot  reach  the  pedicle  or  feel  whether  the  os 
is  present,  the  diagnosis  is  very  difficult.  We  rely  on  careful  abdominal 
palpation  to  ascertain  whether  the  uterus  can  be  felt  resting  on  the  top 
of  the  tumour. 

We  must  not  forget  that  we  may  have  both  conditions  present,  i.e., 
pediculated  fibroid  +  a  certain  amount  of  inversion. 

PROGNOSIS. 

The  prognosis  as  to  danger  to  life  will  depend  on  the  haemorrhage. 
Wherever  a  polypus  is  present,  we  should  advise  its  removal. 

As  to  the  operation,  the  removal  of  mucous  polypi  and  smaller  fibroids 
is  safe  and  easy.  The  fear  of  haemorrhage  from  the  pedicle  of 
a  fibroid  tumour,  which  led  to  the  treatment  by  ligature,  has  been 
found  by  experience  to  have  been  exaggerated.  Where  there  is  a  rigid 
cervix  to  be  dilated  before  we  can  remove  the  tumour,  where  the  tumour 
is  large  so  that  it  must  be  removed  in  portions,  where  there  is  a  thick 
pedicle  and  consequently  a  larger  raw  surface,  the  operation  will  be  a 
more  serious  one  and  the  prognosis  given  more  guardedly. 

Should  there  be  pregnancy,  the  polypus  may  be  removed  without 


458 


AFFECTIONS  OF   UTERUS. 


interrupting  its  course.     If  it  be  of  such  a  size  as  to  interfere  with 
labour,  it  should  be  removed  as  soon  as  discovered. 

TREATMENT. 

Whenever  it  is  necessary  to  dilate  the  cervix  for  diagnosis,  we  should 

have  instruments  ready  to  remove  the 
tumour  at  the  same  time.  The  dilata- 
tion is  effected  by  laminaria  tents,  or 
by  Tait's  graduated  dilators.  A  good 
method  is  to  place  a  laminaria  tent  in 
the  cervix  to  start  the  dilatation ;  after 
six  or  eight  hours  chloroform  the  patient, 
fix  the  cervix  with  volsellse,  and  introduce 
the  graduated  dilators  in  succession  till 
the  cervical  canal  is  wide  enough  to 
admit  the  index  finger;  remove  the 
polypus  by  the  means  to  be  described ; 
wash  out  the  uterine  cavity  with  1  to  60 
carbolic  solution. 

Small  polypoidal  projections  are  re- 
moved with  the  curette,  as  described 
under  Endometritis,  followed  by  the 
application  of  carbolic  acid. 

Mucous  polypi  are  twisted  off  with 
the  forceps,  shown  at  fig.  274.  It  is 
advantageous  to  use  forceps  with  a 
catch,  as  this  keeps  a  steady  hold  of  the 
tumour  and  leaves  the  operator's  fingers 
free  to  twist  the  forceps  round. 

In  removing  fibroids,  we  first  ascer- 
tain the  seat  of  insertion  and  size  of  the 
pedicle.  When  the  tumour  is  small,  we 
can  learn  this  by  the  fingers  ;  when  so 
large  that  we  cannot  get  the  fingers  past 
the  tumour  to  the  pedicle,  we  probe 
round  its  base  with  the  sound  or,  laying 
hold  of  the  tumour  with  forceps,  en- 
deavour to  rotate  it  and  thus  test  the 
thickness  of  the  pedicle. 

The  pedicle  will  yield  to  torsion  with 
the  forceps.  This  is  the  simplest  method 
and  should  always  be  tried  in  the  first  instance  ;  the  forceps  shown 
at  fig.  257,  or  a  pair  of  Nekton's  forceps  (fig.  141),  are  most  suitable. 
If  this  fail,  divide  the  pedicle  with  curved  scissors.  Make  traction 


FIG.  274. 

FORCEPS  WITH  CATCH  FOR  REMOVING 
Mucous  POLYPI. 


POLYPI.  459 

with  the  forceps  to  render  the  pedicle  tense ;  too  forcible  traction 
might  produce  inversion.  Guarding  the  uterine  wall  with  the  fingers, 
carry  in  the  curved  scissors.  In  cutting,  make  the  scissors  hug 
the  surface  of  the  tumour  and  tlms  keep  clear  of  the  uterine  wall. 
Strangulation  by  ligature,  formerly  widely  practised,  is  now  entirely 
abandoned  ;  the  sloughing  stump  was  a  fruitful  source  of  septicaemia. 

When  the  pedicle  is  of  considerable  thickness,  it  may  be  divided  with 
the  ecraseur  or  with  the  gal vano- caustic  wire.  The  wire  ecraseur  is 
preferable  to  the  chain  ecraseur,  as  it  is  more  easily  applied.  For  the 
nature  and  method  of  use  of  the  ecraseur,  the  student  is  referred  to 
Treatment  of  Carcinoma  of  the  Cervix. 

When  the  size  of  the  tumour  makes  the  pedicle  inaccessible,  it  must 
be  diminished.  This  is  best  effected  by  Hegar's  method  :  traction  is 
made  on  the  tumour,  which  is  at  the  same  time  incised  in  a  spiral 
manner  with  scissors ;  the  tumour  is  thus  (as  it  were)  unwound,  till 
finally  the  pedicle  is  reached  and  divided. 

Chloroform  is  not  necessary  for  the  removal  of  smaller  polypi.  The 
section  of  the  pedicle  is  painless  ;  if  pain  be  present  on  tightening  the 
ecraseur  round  the  neck  of  a  polypus,  the  operator  should  examine  care- 
fully again  to  make  sure  that  the  wire  is  not  constricting  the  inverted 
funclus.  Where  the  polypus  is  large  and  the  operation  tedious,  it  is 
better  to  have  the  patient  anaesthetised  as  the  operator  has  then  more 
freedom. 


CHAPTER  XL. 

CARCINOMA  UTERI  (OF  CERVIX):    PATHOLOGY  AND 
ETIOLOGY. 

LITERATURE. 

Harbour — Cases  of  Carcinoma  of  the  Female  Pelvic  Organs:  Edin.  Med.  Jour.,  July 
1880.  Barnes — Diseases  of  "Women,  p.  821  :  London,  1878.  Gusserow — Die 
Neubildungen  des  Uterus,  S.  199 :  Stuttgart,  1885.  Ueber  Carcinoma  uteri,  Volk- 
mann's  Samml.  klin.  Vor.,  N.  18.  Huge  and  Veit — Zur  Pathologie  der  Vaginal- 
portion  :  Stuttgart,  1878.  Der  Krebs  der  Gebarmutter  :  Stuttgart,  1881.  Schrocder 
— Die  Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  264  :  Leipzig,  1878.  Simp- 
son, Sir  J.  Y. — Diseases  of  Women :  Edinburgh,  1872,  p.  140.  Tanner — On 
Cancer  of  Female  Sexual  Organs  :  London,  1863.  Virchow — Ueber  Cancroide  und 
Papillargeschwiilste,  1850.  Williams — Cancer  of  the  Uterus :  London,  1888.  The 
student  will  find  the  fullest  references  to  literature  in  Gusserow's  and  Ruge's. 

THUS  far  we  have  considered  only  the  simple  or  benign  tumours  in  the 
uterus.  We  pass  now  to  the  malignant ;  and  these  present  themselves 
in  three  forms — Malignant  Adenoma,  Carcinoma,  and  Sarcoma.  The 
first  two  differ  from  the  third  in  that,  while  they  are  of  an  epithelial,  it 
is  of  a  connective-tissue  type.  And  the  first  two  differ  between  them- 
selves in  that  the  one  builds  itself  on  the  plan  of  the  uterine  glands,  the 
new-formed  tissue  being  a  reproduction  of  the  branching  cervical  glands 
or  the  tubular  glands  of  the  body  of  the  uterus,  while  the  other  produces 
epithelium  in  an  irregular  manner  in  clusters  and  strings  embedded 
in  a  proliferating  connective  tissue.  The  former  type  of  growth  is  rare 
in  malignant  tumours  of  the  xiterus,  and  our  knowledge  of  it  as  yet 
scanty  ;  so  that,  although  we  shall  have  occasion  to  refer  to  malignant 
adenoma,  we  do  not  describe  it  as  a  separate  variety  of  tumour. 

The  cervix,  as  we  have  seen,  differs  anatomically  from  the  body  of 
the  uterus ;  it  also  differs  pathologically,  i.e.  is  distinctly  marked  off 
from  the  body  of  the  uterus  as  regards  some  of  the  morbid  processes  to 
which  it  is  liable.  We  have  seen  that  while  the  body  of  the  uterus  is 
the  common  seat  of  fibroid  tumours,  the  cervix  is  rarely  so ;  in  cancer  the 
opposite  condition  obtains,  for  the  body  is  rarely,  while  the  cervix  is 
very  often,  attacked  by  it*  When  cancer  of  the  uterus  is  spoken  of,  it 
is  in  fact  almost  always  cancer  of  the  cervix  that  is  meant ;  and  it  is 
the  latter  that  we  have  chiefly  to  consider  here,  for  only  about  2  p.c.  of 
cases  of  cancer  are  in  the  body,  the  remaining  98  p.c.  being  in  the  cervix. 


CARCINOMA    UTERI:   PATHOLOGY.  461 

PATHOLOGY. 

On  no  subject  in  pathology  has  more  been  written  and  a  greater 
variety  of  opinion  expressed  than  on  carcinoma.  We  have  endeavoured 
to  arrange,  in  the  table  on  the  following  page,  the  facts  most  important 
for  the  student  to  know. 

CLASSIFICATION. 

There  are  three  varieties  of  carcinoma  usually  given  in  the  English 
text-books.  These  are  medullary  (encephaloid)  and  scirrhous  cancer, 
and  epithelioma.  Now  the  distinction  between  the  first  two  is  merely 
a  question  of  degree  ;  in  the  former  the  cellular  element,  in  the  latter 
the  fibrous  stroma  is  in  excess.  When  we  say  that  medullary  cancer  is 
frequent  but  scirrhous  rare,  we  only  mean  that  carcinoma  runs  a  rapid 
course  when  it  occurs  in  the  uterus.  The  distinction  between  these  two 
and  epithelioma  is  more  marked  and  is  therefore  given  in  the  table,  but 
it  is  very  doubtful  whether  it  rests  on  a  pathological  basis. 

From  the  above  it  is  evident  that  we  are  not  yet  in  a  position  to  make 
a  scientific  classification.  The  division  according  to  clinical  features 
into  true  carcinoma  and  cancroid  (xapKlvos  and  elSos,  like  cancer)  is  con- 
venient :  it  expresses  nothing  more  than  that  in  some  cases  progress  is 
more  rapid  than  in  others ;  and  that  the  disease  in  the  one  case  pro- 
duces metastatic  deposits,  in  the  other  remains  local. 

ORIGIN. 

As  regards  the  origin,  there  are  two  distinct  views.     That  the  disease  Virchow's 
arises  from  connective-tissue  cells  alone,  is  the  view  maintained  by  Virchow    iew' 
and  his  followers ;  while  Thiersch  and  Waldeyer  hold  that  in  all  cases  it  View  of 
originates  in  epithelial  cells.     In  the  cervix,  as  possible  sources,  there  arean(jers 
two  varieties  of  epithelium;  the  squamous  on  the  vaginal  aspect,  the  Waldeyer. 
cubical  lining  the  canal.     In  the  flat  cancroid  of  the  cervical  canal,  it 
arises  from  the  cubical  epithelium  which  lines  the  latter ;  in  the  papil- 
lary form,  it  originates  in  the  cells  of  the  rete  Malpighi  on  its  outer 
aspect  (Klebs).     It  will  be  seen  that  Waldeyer  holds  the  view  that,  in 
all  cases,  it  arises  from  the  latter  only. 

More  recent  investigations  into  the  origin  of  carcinoma  are  by  Euge  Huge  and 
and  Veit.      According   to  them  carcinoma  arises,  in  the  majority  ofinvest;ga_ 
cases,  from  a  transformation  of  the  connective-tissue  cells ;  even  the  tions. 
papillary  form  which   produces   the   so-called  cauliflower   excrescence, 
although  it  apparently  springs  from  the  epithelium,  is  developed  from 
the  connective  -  tissue   cells.      The   connective  -  tissue  stroma  becomes 
vascular  and  almost  like  granulation  tissue.     The  young  cells,  which 
are  apparently  produced  from  the  connective-tissue  corpuscles,  take  on 
an  epithelial  character.     These  observers  never  saw  plugs  of  epithelium 
extending  downwards  into  the  connective  tissue. 


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CARCINOMA    UTERI:   PATHOLOGY. 


463 


Williams,  on  the  other  hand,  in  figuring  a  specimen  like  one  by  Ruge 
and  Veit,  says  that  the  hypertrophied  connective-tissue  papilla  pushing 


FIG.  275. 

CANCER  or  THE  VAGINAL  PORTION  (/.  Williams). 

a.  Normal  squamous  epithelium  in  the  vaginal  aspect  of  the  cervix  ;  I.  processes  of 
cancerous  cells  which  have  developed  from  it. 

their  way  through  the  proliferating  cancerous  epithelium  (the  super- 
ficial living  layers  of  which  are  shed  in  places)  produce  only  an  appear- 
ance of  their  being  the  starting-point  of  the  disease. 


FIG.  275.* 

CANCER  OF  THE  CERVIX  PROPER  (/.  Williams). 

a.  Normal  columnar  epithelium  lining  a  gland  within  the  cervical  canal ;  6.  cancerous 
cells  derived  immediately  from  it. 

According  to  the  place  in  the  cervix  in  which  it  begins,  we  distinguish 
Cancer  of  the  Vaginal  Portion  from  Cancer  of  the  Cervix  proper — an 


464 


AFFECTIONS  OF  UTERUS. 


important  distinction  which  we  owe  to  Ruge  and  Veit.  It  is  difficult  to 
draw  an  imaginary  line  which  would  divide  the  cervix  into  these  two 
parts ;  but  if  we  hold  to  an  exclusively  epithelial  origin  for  cancer,  we 
can  define  the  former  as  cancer  beginning  in  the  squamous  epithelium  on 
the  vaginal  aspect,  the  latter  as  cancer  beginning  in  the  columnar 
epithelium  lining  the  canal.  Figs.  275  and  275*  illustrate  the  origin 
of  cancer-cells  from  these  two  sources.  Cancer  of  the  vaginal  portion  is 
the  rarer  of  the  two  forms. z 

POSITION. 

Three  There  are  apparently  three  places  in  the  cervix  where  carcinoma  may 

in* Cervix,  develop.  (!•)  It  may  begin  as  hard  nodules  in  the  substance  of  the  cervix 
underneath  the  mucous  membrane ;  these  increase  in  size,  come  to  the 
surface  of  the  mucous  membrane  (fig.  276),  and  produce  ulceration. 
(2.)  More  rarely  does  it  commence  in  the  interior  of  the  cervical  canal  and 
spread  along  its  mucous  membrane  so  as  to  excavate  the  canal.  (3.) 


FIG.  276. 

CARCINOMATOUS  NODULE  GROWING  IK  ONE  LIP  OF  THE  CERVIX  AND  PUSHING  THE  Mucous  MEMBRANE 
OUTWARDS.     The  figure  to  the  right  is  a  section  of  the  cervix  made  through  the  line  x  (Sckroeder). 

It  may  appear  on  the  vaginal  aspect  of  the  cervix  as  an  ulcerating  surface 
(fig.  278)  or  as  an  irregular  papillary  tumour,  which,  extending  down- 
wards into  the  vagina,  attains  considerable  size. 

Form  of          It  is  important  to  remember  that  there  is  a  form  of  slow  ulceration 

Ulceration  on  *^e  surface  of  the  vaginal  portion  which  is  not  malignant.     John 

not  malig-  Williams  2    described  this   as    "  corroding   ulcer   of  the  os  uteri : "  it 

begins  at  the  os  and  extends  symmetrically  downwards  into  the  vagina, 

without  hard  or  thickened  edges,  extending  by  simple  ulceration  or  the 

formation  of  reddish  raised  tubercles  which  ulcerate ;  in  one  case,  there 

was  calcification  of  the  internal  iliac  arteries ;  of  three  cases  observed, 

the  duration  was  in  one  for  two  years   and   in   two   for   ten   years. 

According  to  Matthews  Duncan,  this  is  a  form  of  lupus  which  we  shall 

have  to  notice  specially  as  an  affection  of  the  vulva. 

1  Seven  undoubted  cases  of  it,  and  fifteen  of  cancer  of  the  cervix  proper,  are  described  in  Williams' 
monograph. 

1  Brit.  Med.  Jour.,  April  5,  1884. 


CARCINOMA    UTERI:    PATHOLOGY. 


465 


There  is  also  a  form  of  adenoma  which,  though  it  is  not  malignant 
(v.  p.  452),  tends  to  become  so.  Fiirst 1  has  recorded  a  very  interesting 
case  of  this  in  which  the  amputated  cervix  showed  only  the  appearance 
of  a  cysto-adenoma,  while  18  months  afterwards  the  patient  died  of  true 
cancer  of  the  cervix. 

PROGRESS. 

During  the  first  stage  we  may  distinguish  the  three  forms,  but  after 
ulceration  has  occurred  they  pass  into  one  another  and  are  no  longer 
distinguishable. 

As  regards  the  further  progress,  there  are  three  modes  of  the  spread- 
ing of  the  disease ;  first,  upwards  into  the  body  of  the  uterus ;  second, 
downwards  into  the  vagina;  and,  third,  into  the  connective  tissue  of 


FIG.  277. 

MICROSCOPIC  SECTION  OF  A  PORTION  or  THE  CERVIX  UTERI  SEEN  IN  FIG.  276.  e  squamous  epithelium 
in  several  layers ;  c  »  carcinomatous  nodule  ;  between  these  is  seen  a  portion  of  inflamed  mucous 
membrane  covered  with  a  single  layer  of  epithelium  (Schroeder). 

the  pelvis.  This  last  is  the  most  important.  It  takes  place  either  by  a 
continuous  infiltration  of  the  adjacent  connective  tissue,  or  as  a  chain  of 
nodules  running  in  the  direction  of  the  utero-sacral  ligaments ;  these 
nodules,  probably,  correspond  to  lymphatic  glands. 

Cancer  of  the  vaginal  portion,  according  to  Ruge  and  Veit,  rarely 
spreads  into  the  cervix  but  extends  laterally  into  the  fornices  and 
adjacent  connective  tissue ;  cancer  of  the  cervix  spreads  upwards  into 
the  uterus  and  also  to  the  connective  tissue.  We  shall  see  the  impor- 
tance of  this,  when  we  consider  the  extirpation  of  the  uterus  (v.  p.  494). 

In  cancer  of  the  cervix,  Abel  and  Landau  2  have  found  changes  in  the 

1  Ueber  snspectes  iind  malignes  Cervix-Adenom  :  Zeits.  f.  Gel.  u.  Gyn.,  XIV.,  S.  352. 
-  Ueber  das  Verhalten  der  Schleimhaut  des  Uteruskorpers  bei  Carcinom  der  Portio  vaginalis : 
Archie  f.  Gyn.  XXXII.,  S.  271,  and  XXXV.,  S.  214. 
2  G 


466 


AFFECTIONS  OF  UTERUS. 


mucous  membrane  of  the  body  also — not  only  those  of  chronic  inflamma- 
tion, but  also  of  carcinomatous  degeneration ;  they  further  found  micro- 
scopic changes  exactly  similar  to  sarcoma,  but  which  might  be  the  first 
stage  of  carcinoma  of  the  body. 

Eckart,1  on  the  other  hand,  found  only  hyperplasia  of  the  glands 
with  papillary  proliferation  into  their  lumen,  i.e.  endometritis  glandu- 
laris. 

Saurenhaus,  from  the  examination  of  a  still  larger  amount  of  material,2 
has  shown  that  the  changes,  though  extensive,  are  of  a  benign  charac- 
ter, whether  we  characterise  them  as  a  hyperplastic  endometritis  or  a 
simple  adenoma. 


FIG.  278. 

SECTION  OF  A  FLAT  CANCROID  (EPITHELIOMA)  OF  THE  CERVIX.    «  squamous  epithelium,  cc  carcino- 
matous cells ;  between  these  is  seen  some  granulation  tissue  (Schroeder). 


EXTENSION   TO   NEIGHBOURING   ORGANS. 

In  its  further  progress,  the  carcinomatous  growth  invades  the  sur- 
rounding organs.  Pushing  its  way  forwards  in  the  cellular  tissue 
between  the  bladder  and  the  uterus,  it  involves  the  mucous  membrane 
of  the  former ;  it  first  produces  vesical  catarrh,  then  sloughing  of  the 
walls,  and  finally  vesico-vaginal  fistula.  The  bladder  is  affected  in  a 
considerable  proportion  of  cases ;  of  311  cases  of  cai-cinoma  this  occurred 
in  41  per  cent.,  fistula  resulting  in  18  per  cent.  (Gusseroio).  From  the 
position  of  the  ureters,  they  are  frequently  involved.  The  carcinoma- 
tous growth  may  press  upon  the  ureters  near  their  point  of  entrance  into 
the  bladder ;  or  it  infiltrates  their  walls,  and  the  consequent  thickening 

1  From  the  examination  of  ten  uteri  extirpated  by  Kaltenbach  for  cancer  of  the  cervix :  Centmlb. 
f.  Oyn.,  1888,  S.  426. 

2  Fifty  uteri  extirpated  for  cancer  :  Centralb.f.  Oyn.,  1888,  S.  755. 


CARCINOMA    UTERI:   PATHOLOGY. 


467 


produces  constriction  at  the  part  affected.     Dilation  of  the  ureter  above 
thus  results,  which  produces  hydronephrosis  and  finally  atrophy  of  the 


FIG.  279. 

CARCINOMA  beginning  in  the  CERVIX  UTERI,  and  ending  in  the  production  of  recto-vesico-vagical 

fistula  (Farre). 

kidney.     The  frequency  of  this  condition  will  be  apparent  from  the  fact 
that  Blau  found  it  present  in  57  out  of  93  post-mortem  examinations. 


FIG.  280. 

VERTICAL  MESIAL  SECTION  OF  PELVIS,  FROM  CASE  OF  CARCINOMA  UTERI,  a,  Perineal  body ;  b, 
Symphysis  pubis  ;  c,  Kectum  ;  d,  Body  of  Uterus  ;  e,  Small  fibroid  ;  /,  Urethro- vaginal  septum  ; 
g,  Bladder.  A  small  tube  passes  between  bladder  and  excavated  cervix  through  a  fistula 
(Barbw.r). 

Artaud    describes    two   degrees   of  kidney   affection :    with   moderate 


468 


AFFECTIONS   OF   UTERUS. 


pressure,  the  kidney  is  slightly  enlarged  and  shows  hypertrophy  of  the 
glomeruli  and  dilatation  of  the  convoluted  tubules  with  small-celled 
infiltration  round  both  of  these  and  the  arteries ;  (2)  with  greater 
pressure,  dilatation  of  the  ureters  and  atrophy  of  the  kidney.  More 
rarely  does  the  carcinomatous  infiltration  extend  backwards  into  the 
rectum  and  produce  recto-vaginal  fistula ;  of  282  cases  the  rectum  was 
affected  in  18  per  cent.,  fistula  resulting  in  8*5  per  cent.  (Gwserow).1 
When  both  bladder  and  rectum  have  been  opened  into,  a  common  cloaca 
is  produced  as  in  fig.  279. 

Perforation  into  the  peritoneal  cavity  is  rare.  The  peritoneum  is  not 
simply  pushed  forward,  but  is  taken  up  into  the  carcinomatous  growth. 
As  this  process  goes  on,  adhesions  are  constantly  being  formed  between 
the  walls  of  the  peritoneum  in  front  of  the  growth  so  that  it  does  not 


FIG.  281. 

VERTICAL  MESIAL  SECTION  OF  PELVIS,  FROM  CASE  OF  CARCINOMA  VAGINAE  ET  UTERI.  /,  points  to 
vagina  eroded  by  disease  ;  e  is  a  malignant  growth  attached  to  uterus.  Other  letters  as  in  fig. 
280  (Barbour). 

project  free  into  the  cavity  beyond.  These  adhesions  further  prevent 
the  peritoneal  cavity  from  being  opened  into  when  the  carcinomatous 
mass  breaks  down. 

The  accompanying  sections  (figs.  280,  281),  made  from  post-mortem 
preparations,  will  serve  to  illustrate  some  of  the  points  noted  above. 

Points  to  be  noted  in  fig.  280. 
Descrip-          1.  Seat  of  disease  in  the  cervix  ; 

Pelvis  with     2.  Complete  destruction   of  the   cervix  and   lower  segment  of  the 
uterus ; 


Cancer  of 
Cervix. 


1  Fere  and  Carron  (Statistics  of  Complications  of  Carcinoma  Uteri  in  51  post-mortems  at  the 
Salpetriere  1881-83)  found  extension  to  the  bladder  with  fistula  in  IS,  to  the  rectum  in  7,  and  to  the 
peritoneum  in  9  cases. 


CARCINOMA    UTERI:   ETIOLOGY.  469 

3.  Production   of  an  irregular   cavity   from  the   extension    of    the 
disease  in  three  directions  through  the  cellular  tissue  — 

(a.)  Behind  the  uterus, 

(&.)  Between  the  uterus  and  the  bladder, 

(c.)  Between  the  vagina  and  the  bladder  ; 

4.  The  pouch  of  Douglas  entirely  obliterated  and  partially  replaced 
by  the  carcinomatous  excavation,  the  vesico-uterine  pouch  shortened  by 
adhesions,  perforation  into  the  peritoneal  cavity  at  one  point  ; 

5.  Bladder  small  and  contracted,  carcinomatous  fistula  ; 

6.  Rectum  intact. 

Points  to  be  noted  in  fig.  281. 

1  .  Vagina  (as  well  as   cervix)   affected,  the  nymphae   had   a   cartila-  Descrip- 
girious  consistence,  inguinal  glands  enlarged  —  although  not  shown 


figure  ;  Cancer  of 

Cervix 

2.  Extension  of  the  disease  along  the  mucous  membrane  of  the  uterus, 

excavating  it  though  not  destroying  the  walls  to  the  same  extent  as  in 
fig.  280  ; 

3.  Partial  obliteration  of  the  pouch  of  Douglas  ; 

4.  Bladder  dilated  through  pressure  on  the  urethra,  its  walls  appar- 
ently not  involved  ; 

5.  Rectum  intact. 

ETIOLOGY. 

The  female  sex  is  more  liable  to  carcinoma  than  the  male.  According 
to  Sir  J.  Y.  Simpson's  statistics,  the  proportion  is  2i  to  1.  These 
statistics  are  drawn  from  the  Annual  Reports  of  the  Registrar-General 
for  England  during  the  years  1847-1861.  During  that  time  there  were 
87,348  fatal  cases  of  carcinoma,  of  which  61,715  were  among  women  and 
25,633  among  men.  For  the  year  1860,  the  deaths  from  carcinoma 
among  men  were  '97  per  cent,  of  the  total  male  mortality,  among  women 
2  -2  per  cent.  The  cause  of  this  greater  relative  frequency  is  connected 
with  the  development  of  the  sexual  organs  in  the  female.  Up  to 
puberty,  the  mortality  (from  carcinoma)  of  the  sexes  is  the  same  ;  after- 
wards, the  relative  proportion  of  female  to  male  deaths  gradually  rises 
till  it  attains  its  maximum  about  the  age  of  50,  after  which  it  falls  away 
again  (fig.  282). 

The  diagram  on  page  470  is  based  on  the  statistics  of  91,058  deaths 
in  Great  Britain.  It  brings  out  three  facts  :  the  total  number  of  deaths 
in  each  sex  increases  with  age  to  a  certain  point  ;  the  increase  among 
women  is  relatively  the  greater  ;  it  reaches  its  maximum  at  an  earlier 
age  with  the  female  sex. 

The  most  frequent  seat  is  the  uterus,  where  fully  one-third  of  the 
total  cases  occur  ;  the  next  in  frequency  is  the  mamma. 


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CARCINOMA    UTERI.-   ETIOLOGY.  471 

Although  the  immediate  etiology  of  carcinoma  is  unknown,  there  tire 
certain  causes  general  and  local  which  favour  its  development. 

1.  The  general  predisposing  causes  are  the  following  : — 

Heredity ; 

Age; 

Depreciation  of  the  vital  powers. 

The  influence  of  race  is  brought  out  in  Chisholm's  statistics,  which  Race  and 
show  that  carcinoma  is  more  than  twice  as  frequent  among  the  white 
population  as  among  the  black.     As  regards  heredity  in  families,  much 
less  stress  is  now  laid  upon  this  than  formerly. 

According  to  Gusserow's  statistics,  in  1028  cases  heredity  was  proven 
in  only  79,  that  is  in  about  7 '6  per  cent.  Schroeder,  placing  the 
statistics  of  Sibley  and  of  Barker  together,  shows  that  heredity  has 
been  proven  in  only  8 '2  per  cent.  ;  Picot  places  it  at  13  per  cent. 
These  figures  show  that  we  cannot  lay  much  stress  on  heredity  as  a 
predisposing  cause.  On  the  other  hand,  we  must  remember  that  these 
statistics  are  drawn  principally  from  hospital  reports,  from  a  class  of 
people  who  know  little  about  the  former  history  of  their  families. 

Age  has  undoubtedly  a  considerable  influence  upon  the  frequency  of  Age. 
this  disease.  This  is  evident  from  the  table  given  on  page  472. 
Gusserow  collected  statistics  of  2270  cases  reported  by  various  autho- 
rities. The  mortality  per  cent,  for  various  ages  is  represented  by  the 
curve  in  the  diagram  on  page  472.  From  the  table  it  is  evident  that  car- 
cinoma does  not  occur  before  puberty.  The  proportion  of  cases  below 
20  years  (2  in  2270)  is  so  small  that  it  need  not  be  taken  into  account. 
The  first  glance  at  the  diagram  would  lead  one  to  believe  that  the 
increasing  frequency  of  the  disease  is  due  to  the  development  of  the 
functional  activity  of  the  sexual  organs,  but  a  more  careful  considera- 
tion shows  that  the  increase  continues  and  reaches  its  maximum  after 
the  latter  has  ceased.  This  table  should  be  compared  with  that  for 
Fibroid  Tumours  on  page  414. 

Whatever  tends  to  depreciate  the  vital  powers  favours  the  occurrence  Deprecia- 
of  this  disease.     We  meet  with  it  more  frequently  among  the  poorer  y?^ 
classes,  where  there  is  insufficiency  of  food  with  privation  and  hardship.  Powers. 
Schroeder  contrasts,  in  this  respect,  the  development  of  carcinoma  with 
that  of  myoma.     In  his  polyclinic  among  the  poorer  classes,  the  pro- 
portion of  carcinoma  to  myoma  was  as  100  to  61 ;  in  his  private  practice 
among  the  wealthier,  it  was  as  100  to  332. 

2.  The  local  predisposing  causes  are  the  following  : — 

Erosion  of  the  cervix  and  protracted  catarrh ; 

Repeated  parturition. 

The  relation  of  erosion  and  laceration  of  the  cervix  to  the  development  Influence 
of  carcinoma  has  been  recently  pointed  out  by  Huge  and  Veit  and  also 
by  Breisky.     We  draw  attention  to  this  point  specially,  because  the 
most  important  differential   diagnosis  is   that   between   long-standing 


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CARCINOMA    UTERI:   ETIOLOGY.  473 

inflammation  and  commencing  malignant  disease ;  and  the  possibility 
that  the  former  may  pass  into  the  latter  should  always  be  kept  in 
view. 1 

Repeated  parturition  has  an  important  influence.     Carcinoma  is  much  Influence 
more  frequent  in  multiparse.     Gusserow  finds  an  average  of  5'1  children  pfaj^£te 
to  every  case  of  carcinoma,   which   is  a   high   average   productivity,  tion. 
Whether  this  is  due  to  the  greater  functional  activity  of  the  uterus  or 
to  the  production  of  fissures  with  their  resulting  chronic  inflammatory 
changes,  is  a  more  difficult  question. 

1  Williams,  however,  in  his  cases  never  found  the  disease  starting  in  a  tear,  and  thinks  that  there 
is  no  evidence  that  laceration  plays  any  part  in  the  etiology  of  cancer. 


CHAPTER   XLI. 

CARCINOMA  UTERI  (OF  CERVIX):   SYMPTOMS  AND 
DIAGNOSIS. 

LITERA  TURE. 
See  Literature  of  Chapters  XL.  and  XLII. 

SYMPTOMS. 

The  local  symptoms  of  carcinoma  uteri  are  three  — 
Haemorrhage, 
Offensive  discharge, 
Pain. 

There  are  in  addition  a  considerable  number  of  general  symptoms, 
which  arise  secondarily. 

As  a  rule,  however,  no  symptoms  are  present  in  the  first  stage,  that 
is  until  ulceration  sets  in.  In  exceptional  cases,  when  infiltration  of 
the  connective  tissue  or  of  the  walls  of  the  uterus  has  taken  place  at  an 
early  period,  pain  may  be  an  early  symptom ;  there  is  no  pain  so  long 
as  the  disease  is  limited  to  the  cervix.  This  entire  absence  of  symptoms 
until  the  disease  has  already  made  considerable  progress,  is  the  reason 
of  the  great  difficulty  in  ascertaining  the  period  of  its  probable  com- 
mencement. From  the  same  cause,  the  patient  does  not  seek  relief  till 
the  possibility  of  eradicating  the  disease  is  much  diminished. 

LOCAL   SYMPTOMS. 

Haemor-          Haemorrhage  is  usually  the  first  symptom  noticed  by  the  patient. 

rhage.  g^e  okserves  that  menstruation  is  more  profuse  than  formerly.  This, 
when  the  disease  occurs  late  in  life,  she  attributes  to  approach  of  the 
menopause.  In  other  cases,  profuse  haemorrhage  occurs  irregularly 
between  and  independent  of  the  menstrual  periods.  Sometimes  the 
haemorrhage  is  noticed  only  after  exertion  (as  straining  at  stool)  or  after 
coitus.  Sometimes  the  patient  states  that  "  the  menstrual  flow  never 
entirely  ceases;"  which  means  that  the  vaginal  discharge  is  always 
tinged  with  blood.  The  explanation  of  haemorrhage  in  these  earlier 
stages  is  to  be  found  in  the  vascularity  of  the  stroma  of  the  new  forma- 
tion. It  is  rich  in  delicate  vessels  which  readily  rupture.  In  the  later 
stages,  haemorrhage  is  not  a  prominent  symptom  unless  a  large  vessel 
be  accidentally  eaten  into.  Death  from  haemorrhage  is  rare. 

Discharge.       The  discharge  characteristic  of  carcinoma  is  not  present  until  ulcera- 


CARCINOMA    UTERI:    SYMPTOMS.  475 

tion  has  occurred.  In  the  papillary  form  of  epithelioma1  (cauliflower 
excrescence),  there  is  a  free  dischai'ge  before  the  growth  has  begun  to 
break  down ;  this  is  of  a  watery  character,  has  no  odour,  and  is  due 
simply  to  the  transudation  of  serum.  As  soon,  however,  as  ulceration 
occurs  in  any  of  the  forms,  there  is  a  discharge  containing  the  molecular 
debris  of  the  breaking  down  tissue  which  gives  it  a  characteristic  and 
peculiarly  offensive  odour.  In  the  rapidly  growing  forms  (medullary)  of 
carcinoma,  there  is  an  almost  equally  rapid  molecular  death  of  the  newly 
formed  tissue  due  to  fatty  degeneration  of  the  epithelial  cells.  In  epithe- 
lioma this  discharge  is  less  marked,  because  there  is  less  necrosis  of 
tissue ;  but  in  true  carcinoma,  especially  in  advanced  stages,  it  is  quite 
characteristic.  In  fact,  a  diagnosis  may  be  sometimes  made  merely 
from  the  odour  which  hangs  about  the  person.  At  first  the  discharge 
is  yellowish-white  in  colour,  but  afterwards  from  the  decomposition  of 
the  fatty  cells  it  becomes  of  a  reddish-brown ;  if  there  is  haemorrhage, 
it  will  be  tinged  with  blood. 

Pain  is  not  such  a  constant  symptom  as  is  usually  supposed.  Some  Pain, 
cases  run  their  whole  course  without  the  patient's  complaining  specially 
of  pain.  It  is  not  present  so  long  as  the  disease  is  limited  to  the  cervix ; 
hence  it  is  of  no  use  as  a  diagnostic  of  carcinoma  of  the  cervix  in  its 
early  stage,  unless  the  cellular  tissue  has  been  at  the  same  time  involved. 
But  as  soon  as  the  new  growth  has  extended  upwards  to  the  body  of  the 
uterus  or  to  the  cellular  tissue  of  the  pelvis,  pain  is  produced  through 
pressure  on  or  actual  lesion  of  the  terminations  of  the  nerves.  The 
character  of  the  pain  varies.  It  is  "  a  dull  gnawing  pain  localised  in 
the  pelvis  or  back,"  or  "a  sharp  pain  shooting  through  to  the  back  or 
down  the  thighs  to  the  knees  ; "  this  last  is  caused  by  simple  pressure 
on  the  crural  and  sciatic  nerves  or,  in  the  later  stages,  from  affection  of 
the  cellular  tissue  of  the  nerve  sheaths.  Occasionally  it  is  felt  in  the 
mammse  or  other  seats  of  uterine  sympathetic  pain.  The  intensity  of 
the  pain  varies  also  in  different  cases ;  it  is  marked  where  there  is  more 
formation  of  new  tissue  and  less  ulceration,  that  is  when  there  is  more 
pressure  on  the  nerve  endings.  Thus,  if  there  has  beep  much  deposit 
between  the  uterus  and  the  bladder  accompanied  with  an  increase  of 
pain,  we  find  that  the  pain  diminishes  when  the  mass  breaks  down  and 
a  vesico-vaginal  fistula  is  formed.  We  may  distinguish  between  pain 
due  to  the  development  of  carcinoma,  and  that  produced  by  the 
chronic  peritonitis  which  accompanies  it  when  the  peritoneum 
becomes  affected;  the  latter  produces  great  sensitiveness  of  the 
abdominal  walls  to  pressure,  and  a  board-like  rigidity  from  reflex  spasm 
of  the  muscles. 

1  Though,  as  we  have  said,  we  have  not  at  present  a  truly  pathological  classification  of  the 
different  forms  of  carcinoma,  it  is  convenient,  clinically,  to  use  the  terms  Epithelioma  and  true 
Carcinoma.  By  them  we  do  not  imply  anything  as  to  the  origin  of  the  disease.  By  epithelioma  we 
understand  those  forms  which  begin  more  superficially,  spread  more  slowly,  and  do  not  tend  to 
involve  the  connective  tissue. 


476 


AFFECTIONS   OF   UTERUS. 


Debility. 


Vaginal 
Examina- 
tion. 


GENERAL   SYMPTOMS. 

In  addition  to  these  local  symptoms  which  are  immediately  due  to  the 
carcinomatous  infiltration  and  degeneration,  there  are  more  general 
symptoms  which  arise  secondarily. 

First  we  mention  loss  of  flesh  and  general  debility.  The  patient  may 
continue  healthy  and  well-looking  in  the  early  stages ;  sometimes,  one  is 
surprised  to  find  that  the  disease  is  already  well  advanced  in  a  patient 
who  to  outward  appearance  is  in  perfect  health.  But,  sooner  or  later, 
the  drain  on  the  system  produces  great  emaciation.  The  patient  also 
has  a  careworn  expression,  partly  from  this  loss  of  flesh  and  partly  from 
the  constant  pain ;  from  this  expression  alone,  known  as  the  "  cancerous 
facies,"  the  diagnosis  may  sometimes  be  made. 

The  wasting  (marasmus)  is  occasioned  not  only  by  the  drain  of  the 
new  growth,  but  also  by  disturbances  of  the  digestive  system  which  arise 
in  the  course  of  the  disease.  Loss  of  appetite  may  amount  to  disinclina- 
tion for  food,  and  digestion  is  interfered  with.  This  is  produced  at  first 
sympathetically,  as  in  other  uterine  disorders ;  but  latterly  it  is  due  to 
gastric  catarrh,  constipation,  the  condition  of  the  blood  (ansemia  and 
ursemia),  and  the  unhealthiness  of  the  atmosphere  resulting  from  the 
offensive  discharges. 

There  is,  further,  painful  micturition  and  defcecation  according  to  the 
extent  to  which  the  bladder  and  rectum  are  involved.  The  latter  is 
always  present,  as  the  rectum,  whenever  it  is  distended,  presses  upon 
the  carcinomatous  growth.  When  fistulse  are  produced,  the  urine  and 
fseces  pass  per  vaginam. 

Pruritus  vulvce  frequently  results  from  the  acrid  and  irritating  dis- 
charge, and  from  the  dribbling  of  the  urine  from  a  fistula.  The  skin 
acquires  in  the  later  stages  a  dingy  straw  tint,  which  when  very  marked 
is  suggestive  of  jaundice.  That  disease  may  actually  be  present  when 
there  is  secondary  carcinoma  of  the  liver,  but  this  is  rare.  The  colour 
is  due  to  the  ansemia,  or  (according  to  Barnes)  to  the  absorption  of 
decomposed  faecal  matter  (coprseinia). 

DIAGNOSIS. 

As  the  patient  does  not  seek  advice  till  the  carcinoma  has  begun  to 
ulcerate,  the  physical  signs  have  by  that  time  become  well  marked  and 
the  diagnosis  is  usually  easy. 

On  making  a  vaginal  examination,  the  finger  feels  the  enlarged, 
thickened,  irregular,  everted  lips  of  the  cervix  spreading  like  a  mush- 
room in  the  vagina  (described  by  Malgaigne  as  "  champignons  can- 
cereux  ").  Sometimes  a  distinct  tumour  is  present,  the  form  of  which 
is  sufficiently  indicated  by  the  term  cauliflower  excrescence  (see  fig.  284). 
In  other  cases  the  finger  feels  an  irregular  ulcerated  siirface  in  the 


CARCINOMA    UTERI:   SYMPTOMS. 


477 


position  of  the  cervix,  soft  and  friable  with  hard  and  unyielding  margins. 
The  examining  finger  is  stained  with  blood,  and  the  odour  of  the  dis- 
charge cannot  fail  to  be  recognised.  If  there  is  any  doubt  as  to  diagnosis, 
a  fragment  should  be  removed  and  examined  microscopically.  The 
appearance  of  a  fibrous  stroma  with  alveoli  which  contain  irregular  cells 
of  an  epithelial  type  with  one  or  more  large  nuclei,  will  confirm  the 
diagnosis  of  carcinoma. 

The  speculum  need  not  be  vised  for  the  recognition  of  carcinoma,  except  Speculum, 
in  its  early  stage  or  to  ascertain  more  exactly  the  seat  and  extent  of  the 
growth.     If  the  disease  be  far  advanced  and  the  diagnosis  certain,  the 
introduction  of  it  causes  unnecessary  pain  and  haemorrhage. 

The  rectal  examination  is  valuable,  and  in  these  cases  should  always  Rectal 
be  carefully  carried  out.     It  gives  us  important  information  in  two  dis- 5xamina' 

uQflU 


FIG.  284. 
CAULIFLOWER  EXCRESCENCE  GROWING  FROM  THE  CERVIX  UTERI  (Sir  J.  Y.  Simpson). 

tinct  classes  of  cases.  First,  in  early  carcinoma  or  in  cases  where  there 
is  a  suspicion  of  commencing  carcinoma,  the  cellular  tissue  of  the  pelvis 
should  be  carefully  examined  to  ascertain  whether  any  localised  deposit 
or  enlarged  glands  can  be  felt ;  this  can  be  done  most  easily  by  the 
rectal  examination.  If  it  is  desirable  to  introduce  two  fingers  into  the 
rectum  or  if  the  examination  causes  much  pain,  the  patient  should  be 
narcotised.  Second,  in  cases  of  advanced  carcinoma  where  the  vaginal 
examination  is  difficult  on  account  of  the  haemorrhage  and  pain  which 
it  occasions,  a  more  thorough  examination  can  be  made  per  rectum. 
The  finger  can  reach  higher  up  than  per  vaginam,  and  thus  we  can 
ascertain  the  extent  of  the  carcinomatous  deposit  and  the  size  and 


478  AFFECTIONS  OF  UTERUS. 

mobility  of  the  uterus.  The  condition  of  the  rectal  mucous  membrane 
itself  is  observed  at  the  same  time,  to  ascertain  whether  it  is  already 
involved  in  the  disease.  In  some  cases  the  rectal  examination  is  the 
only  one  possible,  as  in  the  case  of  carcinoma  vaginae  represented  at 
fig.  281  where  the  deposit  round  the  ostium  vaginae  made  the  introduc- 
tion of  the  finger  impossible. 

DIFFERENTIAL   DIAGNOSIS. 

The  following  are  the  most  important  lesions  from  which  carcinoma 
is  to  be  differentiated  : — 

Hypertrophy  of  the  cervix,  with  induration  and  occluded  follicles ; 
Papillary  erosion  or  ectropium,  with  cicatricial  tissue  ; 
Syphilitic  ulceration,  condylomata  on  the  cervix ; 
Small  fibroid  in  the  cervix,  sloughing  polypi ; 
Retained  portions  of  placenta  or  membranes  ; 
Diphtheritic  inflammation  of  the  mucous  membrane  ; 
Sarcoma  of  the  cervix. 

As  regards  the  first  two  of  these,  it  is  evident  that  carcinoma  resembles 
them  only  at  an  early  stage.  But  it  is  precisely  at  this  stage  that  a 
correct  diagnosis  is  all  important  for  treatment.  We  should  also 
remember  (as  Huge  and  Veit  have  pointed  out)  that  these  conditions  may 
be  at  once  the  result  of  chronic  inflammation  and  the  starting-point  of 
malignant  disease.  The  statement  of  the  patient  that  the  symptoms 
Importance  have  existed  for  a  long  time,  should  not  throw  us  off  our  guard.  In  all 
Examina-  cases  in  which  a  patient  over  forty  years  of  age  seeks  advice  with  symptoms 
referable  to  the  pelvis,  a  careful  examination  should  be  made.  We  may 
thus  accidentally  discover  carcinoma  in  an  early  stage,  while  still  within 
the  possibility  of  radical  treatment.  If  the  carcinomatous  infiltration  be 
general  it  cannot  be  distinguished,  except  by  microscopical  examination, 
from  chronic  induration.  When  localised,  the  diseased  part  is  distinctly 
marked  off  from  the  adjoining  tissue,  shows  a  difference  in  its  level,  and 
is  of  a  slightly  yellow  colour  with  granular  yellowish-white  inequalities.1 
Where  there  is  only  suspicion  of  carcinoma,  there  is  no  harm  in  excising 
a  portion  of  the  suspected  part  and  submitting  it  to  microscopic  investi- 
gation. A  careful  examination  per  rectum  of  the  pelvic  cellular  tissue 
should  always  be  made  as  mentioned  above. 

A  superficial  ulcerating  epithelioma  might  be  mistaken  for  a  simple 
erosion,  but  has  thickened  infiltrated  edges.  The  latter  may,  however, 
pass  into  the  former. 

Condylomata  on  the  cervix  simulate  epithelioma,  but  they  disappear 
under  appropriate  treatment.  Syphilitic  ulceration  produces  sometimes. 

1  Stratz — Zur  Diagnose  des  beginnenden  Carcinoma  an  der  Portio :  Zeits.  f.  Gcb.  u.  Gyn.,  Bd. 
XIII.,  S.  89. 


CARCINOMA    UTERI:    SYMPTOMS. 


479 


deep  excavation,  even  a  rectal  fistula.  This  at  the  first  glance  might  be 
taken  for  carcinoma,  but  more  cai'eful  examination  and  inquiry  into  the 
history  of  the  case  will  remove  all  doubt. 

Small  myomata  are  more  sharply  defined  than  a  carcinomatous 
nodule  of  the  same  size,  because  the  surrounding  tissue  is  not 
infiltrated. 

When  a  small  submucous  fibroid  or  a  cervical  polypus  has  ulcerated, 
it  presents  appearances  similar  to  an  ulcerating  carcinomatous  nodule. 
The  former  however  is  firmer  and  fragments  cannot  be  broken  off  by 
the  finger-nail,  while  the  latter  is  friable  and  breaks  down  easily. 

The  possibility  that  carcinoma  may  be  first  noticed  during  the  puer- Carcinoma 
perium  should  always  be  remembered.     There  should  be  no  difficulty  inj?u*^f 
diagnosing  between  carcinoma  of  the  cervix  and  a  retained  portion  ofperium. 
placenta.      If  the  finger  be  passed  in,   it  will   discover  whether  the 
suspected  fungus-like  mass  be  simply  lying  in  the  cervical  canal  or  be 


FIG.  285. 

SCRAPING  FEOM  CARCINOMA  OF  THE  CERVIX,  STAINED  WITH  LOGWOOD, 


;  drawn  by  S.  DeWpine. 


springing  from  its  walls.  We  have  seen  several  cases  of  carcinoma  in 
patients  who  were  supposed  to  be  having  an  abortion.  In  the  case  of 
carcinoma  of  the  fundus,  differential  diagnosis  is  more  difficult  and  will 
be  discussed  under  that  head. 

Diphtheritic  inflammation  of  the  mucous  membrane  may  easily  be  con- 
founded with  ulcerating  carcinoma  (Schroeder).  The  irregular  swelling 
of  the  mucous  membrane  and  the  offensive  discharge  tinged  with  blood, 
which  are  present  in  diphtheritic  inflammation,  may  be  suggestive 
of  carcinoma  at  the  time;  but  this  superficial  resemblance  soon 
disappears. 

Sarcoma  of  the  cervix  is  a  very  rare  condition.  Sarcomatous  tumours 
are  softer  and  grow  more  rapidly  than  carcinomatous.  A  positive 
diagnosis  can  only  be  made  after  microscopical  examination  of  scrapings 
taken  from  the  tumour  (fig.  285). 


480  AFFECTIONS  OF  UTERUS. 

PROGNOSIS. 

The  prognosis  in  carcinoma  is  always  very  grave.  The  possibility  of 
spontaneous  cure  is  a  disputed  point.  There  is  one  apparently  well- 
authenticated  case  recorded  by  Habit.1  Another  is  mentioned  by 
Barnes,2  in  which  there  is  some  doubt  as  to  the  correctness  of  diagnosis. 
The  prognosis  as  to  the  probable  duration  of  life  will  depend  on  the 
extent  to  which  the  disease  has  already  advanced  and  the  possibility  of 
checking  its  progress  or  even  extirpating  it  altogether  by  operative 
interference.  With  regard  to  the  results  of  operative  interference,  see 
under  Treatment. 

As  regards  the  duration  of  disease  if  not  interfered  with,  there  is  a 
slight  difference  of  opinion.  This  may  be  explained  by  the  variable 
period  in  the  course  of  the  disease  at  which  the  symptoms  appear.  Sir 
J.  Y.  Simpson  gives  the  probable  duration  of  life  after  the  detection  of 
the  disease  as  from  2  to  2|-  years ;  Gusserow  and  Schroeder  give  it  as 
from  1  to  1^;  while,  according  to  Fordyce  Barker,  it  is  as  long  as  3 
years  and  8  months.  The  statistics  of  H.  Arnott,  drawn  from  57  care- 
fully observed  cases,  give  the  duration,  after  the  first  symptom  (usually 
a  flooding),  of  true  cancer  as  53'8  weeks;  of  epithelioma,  827  weeks. 
We  may  say  therefore  to  the  patient's  friends  that  the  disease  will  run  a 
course  of  from  one  to  two  years.  It  is  better  not  to  tell  the  patient 
herself  what  her  trouble  is,  though  its  serious  nature  should  not  be 
disguised. 

CAUSES    OF    DEATH. 

The  causes  of  death,  arranged  in  the  order  of  importance,  are  the 
following : — 

Exhaustion, 
Uraemia, 
Peritonitis, 
Septicaemia, 
Haemorrhage. 
Venous  thrombosis. 

Exhaus-          Exhaustion,  under  which  we  include  marasmus,  is  the  result  partly  of 

lon'          the  drain  on  the  system  and  partly  of  the  inability  to  take  food. 

Uraemia.         The  importance  of  urcemia  as  a  frequent  cause  of  death  has  only 

recently  been  pointed  out.     According  to  Seyfert,3  in  the  majority  of 

cases  death  results  from  it.     It  is  due  to  compression  of  the  ureters, 

as  already  described  under  Pathology.     It  may  be  acute,  accompanied 

by  coma  and  convulsions ;  more  generally  it  is  chronic,  and  shows  itself 

in   the   dulness  of  the   patient,  occasional   headache,   and    decreasing 

sensibility  to  pain — which  diminishes  suffering  as  the  disease  approaches 

its  termination. 

1  Sydenham.  Society's  Year  Book,  1864,  page  401.  2  Barnes,  Diseases  of  Women :  London,  1878. 

3  Saxinger,  Pragermed.  Viertdjahrsschrift,  Bel.  I.,  S.  103. 


CARCINOMA    UTERI:   PROGNOSIS. 


481 


Peritonitis  is  sometimes  the  cause  of  death,  but  not  so  frequently  Peritonitis, 
as  one  would  suppose ;  the  disease  is  prevented  from  extending  to  the 
peritoneum  generally  by  the  adhesions  which  are  formed.      When  peri- 
tonitis  occurs,  it  is  localised  and  chronic;  in  some  cases,  however,  a 
general  peritonitis  is  set  up  which  proves  fatal.     Perforation  may  takePerfora- 
place  from  the  sudden  giving  way  of  adhesions ;  the  escape  of  the  car-tion- 
cinomatous  debris  into    the    peritoneal    cavity   produces   death   from 
shock  or  septic  peritonitis.       The  preparation  shown  at  fig.  286  was 
taken   from  a    patient  in  whom  the    cause    of   death  was  rupture   of 


FIG.  286. 

CARCINOMA  OF  THE  CERVIX  LEADING  TO  OCCLUSION  or  os  UTERI,  dilatation  of  uterus  and  perforation 
(A.  H.  Simpson).     Uterus  and  vagina  laid  open  ;  a  quill  is  passed  through  the  perforation. 

the  uterus.  The  case  is  reported  and  the  preparation  described  by  A.  E. 
Simpson  (op.  cit.,  p.  276).  There  was  carcinoma  of  the  cervix  which 
had  contracted  the  lumen  of  the  canal ;  the  cavity  of  the  uterus  was 
expanded,  the  walls  being  thinned  out ;  at  the  fundus  "  was  a  small 
perforation  about  the  size  of  a  pea,  with  thin  edges,"  through  which 
fluid  had  escaped  and  set  up  peritonitis  which  rapidly  proved  fatal. 

Septicaemia  suggests  itself  as  a  likely  cause  of  death.     We  are  familiarsepti- 
with  it  as  produced  in  the  puerperal  condition  :  it  is  explained  by  thecae 


482  AFFECTIONS  OF   UTERUS. 

fact  that,  at  that  time,  there  is  abundant  means  for  absorption  in 
the  numerous  lymphatics  and  large  veins  which  have  been  recently 
lacerated ;  hence,  whenever  septic  matter  is  present,  there  is  great  risk 
of  septicaemia.  Similar  conditions  exist  in  carcinoma,  during  the  pro- 
gress of  which  the  blood  vessels  are  eroded  and  their  extremities  bathed 
in  putrid  matter.  Barnes  has  drawn  special  attention  to  this  as  a 
source  of  blood-poisoning ;  according  to  Eppinger's1  observations  its 
occurrence  is  rare,  and  this  he  ascribes  to  the  diminution  of  the  absorp- 
tive power  of  the  eroded  vessels. 

Hsemor-  Haemorrhage  is  in  very  rare  instances  immediately  fatal.  As  already 
pointed  out,  though  it  is  important  as  an  early  symptom,  it  occurs  less 
frequently  and  is  less  abundant  as  the  disease  advances.  If  a  large 
vessel  be  suddenly  opened  into,  a  fatal  haemorrhage  may  follow. 

Throm-  Venous  thrombosis,  due  to  mechanical  compression  of  the  veins,  some- 

times occurs ;  and  a  clot  may  be  detached  producing  embolism  in  the 
lungs.  Fatty  degeneration  of  the  heart  is,  sometimes,  also  present. 

Patients  with  cancer  have  also  died  of  tetanus,  '2  which  has  been 
ascribed  to  the  action  of  micro-organisms  from  secretion  retained  through 
plugging  of  the  vagina, 

1  Prager  med.  Wochenschrij't,  1876,  S.  210. 

2  See  case  by  Hofmeier:  CentraHi.  f.  Gyn.  Bd.  XI.,  S.  171. 


CHAPTER   XLII. 

CARCINOMA  UTERI  (OF  CERVIX):  TREATMENT. 

LITERATURE. 

Barnes — Diseases  of  Women,  p.  856  :  London,  1879.  Currier,  And.  F. — Removal  of  the 
Uterus  for  Cancer:  N.  Y.  Med.  Jour.,  vol.  xxxiv.,  p.  494.  Duncan,  W.  A. — On 
Extirpation  of  the  entire  Uterus  :  London  Obstet.  Trans.,  1885,  p.  8.  Freund — 
Samm.  klin.  Vortrage,  Nr.  133 ;  and  Centralbl.  f.  Gyn.,  N.  12,  1878.  Gusserow— 
Die  Neubildungeu,  etc. :  Stuttgart,  1885,  S.  199.  Hegar  und  Ealtenbach — Die  Opera- 
tive Gyniikologie,  S.  391.  Hofmcier — Zur  Statistik  des  Gebarmutterkrebses  und 
seiner  opera tiven  Behandlung :  Zeitsch.  f.  Geb.  und  Gyn.,  Bd.  X.,  S.  269.  Lewers 
— On  the  supra-vaginal  amputation  of  the  cervix  uteri  for  malignant  disease,  etc. : 
Lancet,  1888,  I.,  p.  464.  Pawlik — Zur  Frage  der  Behandlung  der  Uteruscarcin.  : 
Wiener  Klinik,  1882,  Hft.  XII.,  S.  425.  Ueber  die  endgtiltige  Heilung  des  Carcin. 
cervic.  uteri  durch  die  operation — Zeits.  f.  Geb.  u.  Gyn.,  Bd.  XIII.,  S.  360.  Sanger 
• — Zur  vaginalen  Totalexstirpation  des  carcinomatosen  Uterus  :  Archiv  f .  Gyn. ,  Bd. 
XXL,  Hft.  I.  Schroeder  —  Charite  Annalen :  V.  Jahrgang,  S.  343,  Zeitschrifi 
fiir  Geburtshulfe  und  Gynakologie :  B.  III.,  S.  419;  B.  VI.,  Heft  II.,  S.  218. 
Simpson,  A.  R. — Carcinoma  Uteri ;  Contributions  to  Obstetrics  and  Gynecology,  p. 
261 :  Edinburgh,  A.  &  C.  Black.  Case  of  Extirpation  of  the  Cancerous  Uterus 
through  the  Vagina :  Edin.  Obst.  Trans.,  vol.  vii.,  p.  136.  Simpson,  Sir  J.  Y. 
— Diseases  of  Women,  p.  170 :  Edinburgh,  1872.  Sims,  Marion — The  Treatment 
of  Epithelioma  of  the  cervix  uteri :  American  Journ.  of  Obst.,  July  1879.  Thomas 
— Diseases  of  Women,  p.  591 :  1882.  Van  de  Warker — A  new  method  of  partial 
Extirpation  of  the  cancerous  Uterus  :  Am.  Journ.  of  Obstet.,  March  1884.  See  also 
Index  of  Recent  Gynecological  Literature  under — Uterus :  Cancer  of,  and  Extirpa- 
tion of  (for  cancer). 

THE  treatment  of  carcinoma  ought  to  be  regarded  in  two  aspects  :  first, 
as  treatment  of  the  symptoms;  second,  as  treatment  of  the  disease. 
Again,  the  treatment  of  the  disease  may  be  either  palliative  or  radical. 

We  need  not  discuss  here  the  vexed  question  whether  carcinoma  is  a 
constitutional  or  a  local  disease.  It  cannot  be  too  strongly  impressed  on 
the  practitioner  that,  as  far  as  our  present  experience  goes,  in  attacking 
the  disease  itself  he  must  rely  upon  surgical  and  not  on  medical  treat- 
ment. Our  aim  ought  to  be  the  removal  of  the  disease  and  not  merely 
the  alleviation  of  the  symptoms.  To  remove  it  completely  we  must 
recognise  it  early.  Up  to  the  present  time  successful  treatment  has  been 
a  rare  occurrence,  because  we  have  failed  to  recognise  carcinoma  in  its 
commencing  stages.  The  possibility  of  treating  it  successfully  in  the 
future  will  depend  on  the  possibility  of  our  recognising  it  in  its  com- 
mencement. Not  less  important  than  early  recognition  is  complete 
removal  and  that  without  delay.  In  the  uterus,  more  readily  than  in 


484  AFFECTIONS  OF  UTERUS. 

the  mamma,  does  the  carcinoma  get  beyond  the  reach  of  the  operator. 
In  carcinoma  mammae,  we  can  excise  not  only  the  breast  but  also  the 
axillary  glands  if  these  should  be  already  implicated.  But,  in  carcinoma 
uteri,  as  soon  as  the  pelvic  glands  are  involved  the  case  is  hopeless  as 
regards  a  radical  cure. 

We  shall  consider,  first,  the  treatment  of  the  symptoms ;  because,  in 
the  majority  of  cases,  when  the  patient  comes  under  our  notice,  the 
disease  itself  has  already  got  beyond  our  remedies. 

TREATMENT    OP    SYMPTOMS. 
These  are  haemorrhage,  offensive  discharge,  pain. 

HAEMORRHAGE. 

In  the  treatment  of  haemorrhage,  there  are  two  points  to  be  con- 
sidered :  first,  the  instructions  to  be  given  to  the  patient ;  and,  second, 
the  means  which  we  can  ourselves  employ. 

Use  of  (1.)  The  patient  is  instructed  to  take  the  liquid  extract  of  ergot  in 

large  doses  whenever  there  is  much  haemorrhage  either  during  the  men- 
strual period  or  independent  of  it.  If  she  is  subject  to  floodings,  a 
friend  might  be  taught  how  to  give  the  ergotin  solution  hypodermically. 
Ice  applied  to  the  vagina  and  injections  of  cold  water  check  haemorrhage; 
a  small  piece  of  sponge  or  tampon  of  wadding,  soaked  in  perchloride  of 
iron,  might  be  passed  into  the  vagina  if  cold  is  not  sufficient.  The 
patient  is  recommended  to  avoid  sexual  intercoiirse,  as  this  favours 
active  congestion  and  in  some  cases  is  the  cause  of  haemorrhage. 
The  (2.)  The  means  at  our  own  command  are  the  following  : — 

Tampon.  Simple  pressure,  effected  by  complete  and  thorough  plugging  of 

the  vagina ; 

The  use  of  styptics,  caustics,  or  the  actual  cautery ; 
The  removal  of  diseased  tissue  by  the  curette  or  other  means. 
The  plugging  of  the  vagina  should  be  done  whenever  we  are  called  in 
on  account  of  profuse  haemorrhage.     The  packing  is  carefully  done  with 
pledgets  of  lint  or  cotton  wadding  (with  string  attached)  soaked  in  car- 
bolic oil ;  the  speculum  is  introduced  carefully  and  not  carried  high  up. 
Of  styptics,  the  best  are  the  perchloride  and  the  pernitrate  of  iron. 
Sir.  J.  Y.  Simpson  recommended  a  saturated  solution  of  the  perchloride 
in  glycerine.      A  pledget  soaked  in  either  of  these  is  introduced,  and 
placed  so  as  to  be  in  contact  with  the  bleeding  surface  ;  and  the  rest  of 
the  vagina  is  packed,  as  above  described,  with  the  pledgets  steeped  in 
carbolic  oil.     The  perchloride  should  be  used  with  great  caution  in  cases 
of  advanced  ulceration,  as  we  have  seen  it  corrode  into  the  tissue  so  as 
to  reach  the  peritoneum  and  produce  peritonitis.     The  use  of  caustics,, 
cautery,  and  curette,  will  be  considered  under  Operative  Treatment. 


CARCINOMA   UTERI:   TREATMENT  OF  SYMPTOMS.    485 


OFFENSIVE   DISCHARGE. 

This  is  best  treated  by  astringent  and  antiseptic  injections.  These 
should  be  used  frequently,  as  it  is  important  to  keep  down  the 
unpleasant  odour  and  make  the  patient's  surroundings  as  comfort- 
able as  possible.  If  the  discharge  be  plentiful  and  not  very  offensive, 
as  in  the  cauliflower  excrescence,  the  indication  is  more  for  the 
use  of  astringents  like  sulphate  of  alumina  and  iron  (4  grains  to 
the  oz.).  Tannin  or  sulphate  of  zinc  can  also  be  used,  and  it  is 
well  to  change  the  astringent  occasionally.  If  there  is  much  necrosis 
of  tissue  with  very  offensive  discharge,  carbolised  water  (1  to  50)  is 
required. 

Acetate  of  lead  (51  to  §20)  is  recommended  by  Barnes.  Solution  of 
bromine  (1  of  the  B.P.  solution  to  3  of  water)  is  a  good  disinfectant, 
but  its  odour  is  disagreeable.  Condy's  fluid  is  largely  used,  but  it  is 
only  deodorant  not  disinfectant.  The  skin  round  the  external  genitals 
should  in  all  cases  be  protected  from  the  acrid  discharges,  as  the  irrita- 
tion is  a  source  of  discomfort.  A  lotion  of  equal  parts  of  olive  oil  and 
glycerine  or  of  olive  oil  and  lime  water,  applied  after  each  vaginal  injec- 
tion, serves  this  purpose  well. 

PAIN. 

This  can  be  effectually  relieved  only  by  some  preparation  of  opium  ;  Use  of 
it  is  well  to  delay  the  habitual  use  of  this  remedy  as  long  as  possible,  as   plum* 
it  interferes  with  digestion  and  nutrition.    It  may  be  given  as  a  morphina 
suppository  (£  of  a  grain  in  each)  per  rectum,  or  as  the  liquor  morphina) 
hydrochloratis  by  the  mouth.     We  obtain  its  action  most  surely  and 
quickly  and  with  the  least  disturbance  of  the  digestive  system  by  giving 
it  hypodermically.     It  is  desirable  to  change  the  narcotic,  as  even  opium 
gradually  loses  its  effect ;  the  hydrate  of  chloral,  in  20  grain  doses,  may 
be  used  as  a  substitute.     Various  local  anodynes  have  been  suggested, 
but  are  of  little  use. 

Attention  to  the  general  condition  of  the  patient  is  very  important.  General 
The  three  main  points  are  to  give  a  sufficient  quantity  of  nutritious  an 
easily  digestible  food,  to  keep  the  bowels  regular,  and  to  have  the 
atmosphere  healthy  and  the  surroundings  cheerful.  Food  should  be 
given  in  small  quantities  and  frequently;  milk,  eggs  and  beef-tea 
should  be  substituted  for  more  solid  food  as  soon  as  digestion  fails. 
In  the  later  stages,  the  bowels  should  be  evacuated  by  enemata 
rather  than  by  purgative  medicines.  The  room  shoitld  be  well  venti- 
lated by  day  and  night,  and  the  vaginal  injections  repeated  fre- 
qiiently.  Gusserow  recommends  that  during  the  night  a  piece  of 
waterproof  sheeting  be  tied  round  the  patient's  waist  to  keep  down 
the  disagreeable  odour. 


486  AFFECTIONS  OF  UTERUS. 


TREATMENT    OF    THE    DISEASE. 

As  before  stated,  our  aim  here  is  extirpation.     If  complete  removal 
be  possible,  carcinoma  will  be  no  longer  the  inciirable  disease  which 
haunts  the  mind  of  the  patient  and  baffles  the  skill  of  the  practitioner. 
The  principles  of  treatment  can  be  best  understood  by  considering  the 
Diagram     progress  of  the  disease  as  consisting  of  three  stages:   (1)  when  the 
of  Cancer,  disease  is  present  as  a  germ  infiltrating  healthy  tissue ;  (2)  when  the 
germ  has  developed  into  a  tissue   having  the  typical   carcinomatous 
structure  ;  (3)  when  this  newly-formed  tissue  breaks  down.     The  accom- 
panying diagram  (fig.  287)  illustrates  this  progress.     The  three  stages 
are  represented  by  three  zones. 

The  extent  of  zone  1  is  not  well  defined,  for  we  have  no  means,  unless 
with  the  microscope,  of  ascertaining  how  far  the  surrounding  tissue  is 
infiltrated.  The  area  of  zone  2  is  more  definite ;  the  line  a  b  c  is  well 
marked,  for  the  carcinomatous  tissue  when  fully  formed  has  charac- 
teristics by  which  it  can  be  recognised  from  the  surrounding  healthy 


FIG.  287. 

DIAGRAM  TO  ILLUSTRATE  THE  SPREADING  OK  CARCINOMA.     1,  Healthy  tissue  infiltrated  with  germs  of 
Carcinoma  ;  2,  Carcinomatous  tissue  fully  developed  ;  3,  Carcinomatous  tissue  breaking  down. 

tissue  by  touch  or  sight.  Zone  3  represents  the  third  stage,  in  which 
the  immediate  danger  to  the  patient  lies.  It  is  not  the  formation  of  the 
carcinomatous  tissue  which  is  dangerous,  but  its  ulceration  with  accom- 
panying haemorrhage  and  exhausting  discharge. 

From  these  facts  we  deduce  the  following  principles  of  treatment. 
First,  to  effect  radical  cure  we  must  remove  zone  1,  as  well  as  zones  2 
and  3  ;  i.e.,  we  must  remove  not  only  the  tissue  which  is  evidently 
carcinomatous,  but  also  all  the  surrounding  tissue  which  may  contain 
germs  of  the  disease.  Sometimes  by  a  chance  the  operator  has  done  this 
through  keeping  well  clear  of  the  evidently  diseased  part,  and  thus  we 
can  explain  the  few  recorded  cases  of  cure.  Second,  we  may  anticipate 
the  natural  process  of  breaking  down,  with  its  accompanying  exhaust- 
ing results  and  risks  of  a  fatal  haemorrhage,  by  destroying  the  newly 
formed  carcinomatous  tissue  as  far  as  it  is  recognisable.  We  shall  thus 
save  the  patient  from  the  effects  of  the  disease  until  zone  1  has  passed 


CARCINOMA   UTERI:   TREATMENT  OF  DISEASE,     487 

into  the  condition  of  zone  2  and  is  beginning  to  break  down.  Thus  we 
explain  the  temporary  benefit  (for  a  period  measurable  by  months) 
derived  from  the  partial  excision  of  the  new  growth.  Third,  the  appli- 
cation of  caustics  alone  may  effect  the  destruction  of  area  2  ;  but  we 
are  not  so  sure  that  we  are  removing  the  lohole  up  to  line  a  b  c, 
as  we  are  when  using  the  knife  or  other  cutting  instrument.  The 
latter  means  is  preferable  because  we  can  make  certain  that  we  have 
reached  this  line  in  all  cases  where  it  is  attainable  by  operation. 
Fourth,  the  use  of  the  knife  and  the  application  of  caustic  to  the  raw 
surface  will,  where  the  disease  has  spread  far,  be  more  effectual  than  the 
use  of  the  knife  alone ;  the  caustic  will  now  without  doubt  operate  on 
the  area  of  zone  1  and  destroy  so  far  the  germs  of  the  disease  : — 
There  are  four  methods  of  operative  treatment  :— 

1.  Application  of  caustics, 

2.  Scraping  out  of  diseased  tissues, 

3.  Amputation  of  the  cervix, 

4.  Excision  of  the  uterus. 

APPLICATION    OF    CAUSTICS. 

This  should  scarcely  come  under  the  head  of  treatment  of  the  dis- Caustics 
ease.  All  that  we  can  hope  for  in  the  application  of  caustics  is  merely  J? 
a  superficial  destruction  of  the  growth  and  consequent  temporary 
alleviation  of  the  distressing  symptoms.  The  caustics  which  we  may 
use  are  the  following.  Strong  nitric  acid  is  applied  with  a  dossil  of  lint, 
the  diseased  surface  having  first  of  all  been  washed  and  carefully  dried 
in  order  to  prevent  the  acid  from  running ;  it  is  again  washed  to  remove 
superfluoiis  acid.  An  alcoholic  solution  of  Bromine  (1  to  5)  has  been 
recommended  by  Routh  -1  and  Wynn  Williams ;  2  cotton  wadding  soaked 
in  it  is  applied  to  the  diseased  part  to  produce  a  sloiigh,  and  the  rest  of 
the  vagina  protected  by  wadding  wet  with  bicarbonate  of  soda.  Numerous 
other  caustics  have  been  tried. 

The  results  of  this  method  are  only  temporary.  The  superficial  layers  of  the  growth 
are  destroyed  while  the  haemorrhage  and  discharge  cease  for  a  time.  Cicatricial 
contraction  takes  place  on  the  surface,  but  the  hard  infiltration  can  be  felt  extending 
beyond.  According  to  Campbell  de  Morgan,3  the  superficial  application  of  caustics  acts 
as  an  irritant]produeing  increased  growth  of  the  new  formation ;  so  that  when  they  are 
used  they  must  be  applied  thoroughly. 

SCRAPING    OUT    OF   DISEASED    TISSUE. 

We  have  recourse  to  this  means  of  treatment  (1)  in  cases  in  which 
the  disease  is  not  of  a  form  suitable  for  amputation — when  it  does  not 
form  a  pediculated  mass  but  is  spreading  along  the  mucous  membrane 

1  British  Medical  Journal,  February  and  March  1880. 

2  London  Obstetrical  Transactions,  vol.  xii.,  p.  249. 

x  "The  origin  of  Cancer  considered  with  reference  to  the  treatment  of  the  disease,  "  1872. 


488 


AFFECTIONS  OF   UTERUS. 


of  the  vagina,  (2)  in  cases  which  are  too  far  advanced  for  amputation  of 
the  cervix.  This  method  is  good  and  safe  in  principle,  because  the 
carcinomatons  tissue  is  soft  and  friable  compared  with  the  surrounding 
connective  tissue  and  can  be  therefore  easily  scraped  away. 

Curette  in  The  means  which  we  employ  are  the  curette  or  the  sharp  spoon.  Sir 
Carcinoma.  J-  Y.  Simpson  used  to  scrape  out  the  diseased  tissue  with  the  finger-nail 
or  the  curette.  The  sharp  spoon  introduced  by  Simon  x  is  the  most 
efficient  instrument :  it  should  be  used  with  short  firm  strokes,  and  the 
raw  surface  examined  from  time  to  time  with  the  finger  to  feel  whether 
all  the  hard  nodules  have  been  removed.  After  the  scraping  has  been 
thoroughly  carried  out,  the  surface  is  burned  by  the  actual  cautery  and 
the  vagina  tamponed  to  prevent  haemorrhage.  The  results  of  this 
method  are  more  satisfactory  than  those  which  follow  the  application 
of  caustic  alone ;  they  depend  entirely  on  the  thoroughness  with  which 
the  scraping  has  been  done. 

AMPUTATION   OF   THE   CERVIX. 

This  operation  is  called  for  by  two  sets  of  circumstances :  (a)  when 
the  disease  is  as  yet  limited  to  the  cervix  and  there  is  a  distinct  line  of 


Ecraseur 

and 

Galvano- 

Cautery 

compared. 


FIG.  288. 
SIMON'S  SHARP  SPOON. 

demarcation  above,  so  that  in  operating  we  can  cut  through  healthy 
tissues ;  (6)  when  it  has  spread  so  far  that  although  we  cannot  operate 
upon  healthy  tissue,  we  are  yet  justified  in  removing  as  far  as  possible 
the  projecting  mass. 

The  means  of  amputation  are  the  following  : — 

Ecraseur,  or  galvano-cautery ; 

Knife  and  scissors,  followed  by  ligature  or  caustics. 

I.  ECRASEUR,  OR  GALVANO-CAUTERY. 

Relative  advantages.  Both  of  these  possess  the  advantages  that  they 
are  easy  of  application  and  cause  less  haemorrhage  than  the  knife, 
although  with  the  latter  we  can  follow  more  certainly  the  line  of  demar- 
cation. The  ecraseur  has  the  advantage  that  it  is  easily  portable, 
requires  no  preparation,  and  is  always  ready  when  wanted.  On  the  other 
hand,  there  is  danger  that  the  peritoneum  of  the  pouch  of  Douglas  or 
of  the  bladder  may  be  lacerated  by  the  chain.  The  galvano-cautery 
is  inconvenient  to  carry  about  and  is  not  always  ready  when  wanted, 

1  Berlin,  Beitrcig.  zur  Geburt.  u.  Gyn.,  1872,  13d.  I. 


CARCINOMA   UTERI:   TREATMENT  OF  DISEASE.     489 


but  has  the  advantage  that  we  do  not  need  to  draw  down  the  uterus 
to  apply  it ;  in  all  cases  of  operation  upon  the  cervix  for  carcinoma,  the 
less  traction  that  is  made  upon  the 
uterus  the  safer  for  the  patient. 
As  the  ordinary  ecraseur  (fig.  289) 
has  the  chain  in  a  line  with  the 
handle,  the  cervix  must  be  drawn 
down  to  the  vulva  for  the  working 
of  the  instrument.  This  difficulty 
is  obviated  in  the  curved  form  of 
instrument,  and  in  the  wire  ecraseur 
devised  by  Sir  J.  Y.  Simpson.  The 
galvano-cautery  not  only  amputates 
but,  at  the  same  time,  cauterises  the 
stump ;  this  is  a  questionable  advan- 
tage as,  though  it  may  diminish  the 
probability  of  haemorrhage,  it  pre- 
vents us  from  examining  whether 
all  the  diseased  tissue  has  been 
removed. 

Mode  of  employment.  Put  the 
patient  under  chloroform.  If  the 
curved  ecraseur  or  the  galvano- 
caustic  wire  be  used,  place  the 
patient  semi  -  prone  ;  only  one  as- 
sistant is  necessary  —  to  hold  the 
Sims  speculum.  If  the  straight 
ecraseur  is  used  or  it  is  desirable 
to  have  the  parts  well  exposed,  the 
lithotomy  posture  is  better ;  the  two 
assistants  who  hold  the  legs  can  at 
the  same  time  draw  aside  the  labia 
with  retractors,  while  a  third  draws 
back  the  posterior  vaginal  wall  and 
perineum  with  the  Sims  speculum. 
Now  lay  hold  of  the  cervix  or 
tumour  with  volsellee,  and  if  neces- 
sary draw  it  down  to  the  vulvar 
orifice.  Place  the  wire  or  chain 
round  the  cervix  or  the  pedicle  of 

the    CarcinomatOUS    maSS    (fig.     290), 

as  far  above  the  limits  of  the  dis- 
ease as  possible,  so  as  to  cut  through  healthy  tissue,  but  not  above 
the  line  of  reflexion  of  the  mucous  membrane  of  the  posterior  fornix 


FIG.  289. 
ORDINARY  CHAIN  ECRASECR. 

n  in  by  a  pumping  motion  of  the  large 


Mode  of 

using 

Ecraseur. 


490 


AFFECTIONS   OF   UTERUS. 


Method 
of  using 
Galvano- 
Cautery. 


upon  the  vaginal  portion  lest  it  should  cut  into  the  pouch  of  Douglas. 
After  the  ecrasexir  has  begun  to  crush  the  tissues,  work  it  slowly — 
shortening  the  loop  at  the  rate  of  one  notch  in  every  twenty  to  thirty 
seconds. 

In  using  the  galvano-caustic  wire  place  it  in  position  cold,  tighten  it 
up  so  as  to  constrict  the  cervix,  and  then  make  the  current.  To  pre- 
vent the  slipping  of  the  wire,  Thomas  has  devised  forceps  with  shoulders, 
which  he  uses  in  place  of  volsellse.  Byrne  of  Brooklyn,  who  has  had  a 


FIG.  290. 

STRAIGHT  ECRASEUR  IN  POSITION.    A  cervix  drawn  to  vulva  with  Museux's  forceps ; 
C  D  chain  ;  E  stem  of  ecraseur  (Chassaignac). 

large  experience  with  the  galvano-cautery,  has  pointed  out  that  if 
gradual  traction  be  made  on  the  cervix  during  the  action  of  the  wire 
the  result  will  be  a  funnel-shaped  excavation ;  by  this  means  more  of 
the  cervix  will  be  removed.  Tighten  the  wire  gradually,  so  as  to  burn 
through — not  cut — the  tissue.  After  amputation,  examine  the  surface 
of  the  stump.  If  there  is  much  haemorrhage,  apply  a  styptic  to  the 
stump  directly  or  on  a  pledget  of  cotton  wadding,  and  pack  the  vagina 


CARCINOMA  UTERI:   TREATMENT  OF  DISEASE.     491 

with  carbolised  lint  or  wadding ;  this  packing  should  not  be  discarded 
for  a  week  or  ten  days,  as  the  great  after-danger  is  haemorrhage. 

Several  cases  of  cure  have  certainly  been  observed,  but  only  where  the  whole  disease 
has  been  removed. 

Sir  J.  Y.  Simpson  records  three  cases.  In  the  first  the  patient  was  well  eighteen  years 
after  the  operation  and  had,  in  the  meantime,  given  birth  to  five  children.  Another 
patient  died,  four  years  after  removal  of  the  disease,  of  cancer  of  the  peritoneum,  there 
having  been  no  local  return.  The  third  died  after  four  years,  of  dysentery. 

Ziemssen,  Barnes,  Byrne,  A.  K.  Simpson,  Thomas  and  others  also  record  several 
successful  cases. 

The  most  interesting  statistics  of  amputation  of  the  carcinomatous  cervix  with  the 
galvano-cautery  are  those  given  by  Pawlik.  He  has  gone  into  the  after  history  of  the 
one  hundred  and  thirty-six  cases  operated  on  by  C.  Braun  in  the  Vienna  Clinic  since 
1861.  The  mortality  from  the  operation  was  7 3  per  cent.  ;  26  of  the  cases  were  still 
without  a  recurrence  two  years  after  the  operation,  the  longest  period  being  19i  years. 
None  of  the  patients  gave  birth  to  a  viable  child  after  the  operation,  abortion  always 
occurring. 

II.  KNIFE  AND  SCISSORS.  The  advantage  claimed  for  this  method  of 
operating  is  that  it  allows  the  operator  to  follow  the  line  of  demarcation 
between  the  diseased  and  the  healthy  tissues ;  if  in  the  coiirse  of  the 
amputation  he  finds  the  carcinomatous  new  formation  extending  higher 
up  than  he  anticipated,  he  can  remove  as  much  more  of  the  suspected 
part  as  may  be  necessary. 

There  are  disadvantages  in  stitching  up  the  Avound  so  as  to  produce 
union  by  first  intention.  We  must  save  enough  mucoiis  membrane  to 
close  in  the  wound,  which  would  be  cut  away  were  we  to  leave  the 
wound  to  granulate  ;  and  in  this,  diseased  tissue  may  be  left.  Further, 
in  the  wound  itself,  germs  of  the  disease  may  be  present  which  would 
be  destroyed  by  the  subsequent  application  of  caustic. 

As  examples  of  amputation  by  the  knife  and  closure  of  the  wound  by 
sutures,  we  shall  describe  the  method  adopted  by  Schroeder  of  Berlin. 
According  to  the  extent  of  tissue  to  be  removed,  he  performs  either  (a) 
amputation  of  the  vaginal  portion,  or  (6)  supra-vaginal  excision  of  the 
whole  cervix. 

A.  Amputation  of  tlie  vaginal  portion.     The  cervix  is  divided  on  both 
sides  with  the  scissors  so  that  distinct  anterior  and  posterior  lips  are 
produced.      A   wedge-shaped   portion  is  excised  out  of  each  of  these 
(fig.  168)  and  the  flaps  stitched  together.     The  lateral  incisions  in  the 
cervix  are  then  closed  by  sutures. 

B.  Supravaginal  incision  of  the  whole  cervix.      1.  The  cervix  having  Schroeder's 
been  drawn  down  with  the  volsella,  or  with  a  hook  if  the  tissue  is  friable,  j^p^t. 
the  knife  is  carried  through  the  vaginal  mucous  membrane  of  the  anterior  ing  Cervix. 
fornix  round  the  base  of  the  anterior  lip  into  the  cellular  tissues  below 

(and  beyond  the  diseased  tissue).  The  bladder  is  easily  separated  from 
the  cervix  almost  as  far  as  the  utero-vesical  pouch  of  peritoneum,  and 
retracts  upwards  carrying  the  ureters  with  it ;  a  sound  must  be  passed 
into  it,  to  define  its  position. 


492  AFFECTIONS  OF  UTERUS. 

2.  The  cervix  is  now  carried  forwards  ;  and  the  mucous  membrane  of 
the  posterior  fornix,  which  is  thus  exposed,  is  incised  in  a  similar  way, 
the  ends  of  this  incision  being  made  continuous  with  those  of  that  made 
in  the  anterior  fornix.      The  peritoneum  of  the  pouch  of  Douglas  is 
liable  to  injury,  but  this  accident  is  not  of  importance.     In  cases  where 
the  posterior  lip  must  be  divided  high  up,  it  is  better  to  cut  into  the 
pouch  and   remove   the   peritoneal   covering   along   with   the   portion 
amputated. 

3.  The  clearing  of  the  cervix  from  the  cellular  tissue  above  the  lateral 
fornices  is  more  difficult,  on  account  of  the  firmness  of  the  connective 
tissue  and  the  presence  of  large  branches  of  the  uterine  artery  which 
enter  at  the  sides.     To  prevent  haemorrhage,  the  tissues  are  transfixed 
with  an  aneurism  needle  and  ligatured  before  cutting  through  between 
the  ligature  and  cervix ;  or  the  tissue  may  be  clamped  in  Wells'  forceps 
and  the  forceps  left  on  for  forty-eight  hours  (Lewers). 


FIG.  291. 

LINE  OF  INCISION  AND  POSITION'  OF  SUTURES  IN  THF,  SUPRA-VAGINAL  AMPUTATION  OF  THE 
CERVIX  (Schroeder). 

4.  The  cervix  being  thus  made  free  all  round,  the  knife  is  carried 
through  its  anterior  wall  at  the  desired  height,  till  the  cervical  canal  is 
opened  into.  The  anterior  vaginal  wall  is  stitched  to  the  anterior  wall 
of  the  cervix  (fig.  291).  This  prevents  retraction  of  the  cervix  while 
the  posterior  wall  is  cut  through  and  the  amputation  thus  completed. 
The  posterior  vaginal  wall  is  now  stitched  to  the  posterior  lip  of  the 
cervix.  The  ends  of  the  wound  in  the  lateral  fornices  are  closed 
with  sutures  which,  if  placed  deeply,  also  control  haemorrhage.  As 
the  ureters  retract,  they  are  not  in  danger  of  being  caught  in  the 
ligatures. 

As  regards  the  operation  itself,  Hofmeier  reporting  on  105  cases  done 
in  Schroeder's  Clinic  gives  a  mortality  of  12-37  per  cent.;  as  regards 


CARCINOMA  UTERI:   TREATMENT  OF  DISEASE.     493 

the  cure  of  the  disease,  out  of  forty-seven  cases,  fifteen  were  -without 
recurrence  two  years  after  the  operation  and  ten  had  not  been 
heard  of;  after  three  years  twelve  were  well  and  after  four  years  five. 
All  the  others  were  lost  sight  of  or  had  a  return  of  the  disease.  Lewers 
reports  on  ten  cases  he  has  done,  all  of  which  recovered  from  the  opera- 
tion: three  had  no  recurrence  till  a  year  afterwards;  and,  in  one  of  these, 
removal  of  the  new  growth  in  the  stump  with  the  cautery  had  given  at 
least  another  year's  immunity. 

Amputation   followed    by   caustics   was  the   method   advocated    by 
Marion  Sims. 


FIG.  292. 
EXCISION  OF  EPITHELIOMA  OF  THE  CERVIX  (Marion  Sims).    For  letters  see  text. 

1.  The  epitheliomatous  mass  is  broken  down  and  removed  with  the  curette,  or  cut 
away  with  the  scissors  if  it  is  of  a  sufficiently  firm  consistence.     It  is  not  merely  removed 
as  far  as  its  base  (dotted  line  a,  fig.  292),  but  the  bed  of  the  tumour  is  exsected  with  the 
knife  and  scissors  or  scraped  out  with  the  curette  as  far  as  diseased  tissue  is  present 
(dotted  line  I,  fig.  292). 

2.  The  cavity  thus  produced  is  cleaned  out  with  sponges,  and  examined  with  the  finger 
to  ascertain  that  all  indurated  structure  has  been  removed. 

3.  The  edges  of  the  cavernous  opening  are  trimmed.     The  parts  are  sponged  quite  dry, 
and  the  cavity  plugged  with  cotton  wool  squeezed  almost  dry  out  of  either  of  the  following 
styptic  solutions ;  liquor  ferri  subsulphatis  (1  part  to  2  of  water),  or  solution  of  carbolic 
(1  to  40)  saturated  with  pulverised  alum  (1  to  12).     The  upper  third  of  the  vagina  is 
packed  with   the  same  material,   and   the  rest   with  cotton  wool  soaked  in  carbolic 
solution. 


494  AFFECTIONS  OF   UTERUS. 

4.  After  an  interval  of  five  days,  this  plug  is  removed  and  the  caustic  introduced. 
Pledgets  of  cotton  wadding  soaked  in  a  strong  solution  of  chloride  of  zinc  (3v  to  gi)  and 
wrung  dry,  are  packed  into  the  scraped-out  cavity  ;  the  upper  part  of  the  vagina  is  tam- 
poned with  wadding  soaked  in  a  solution  of  bicarbonate  of  soda.     Morphia  is  given  hypo- 
dermically  to  relieve  the  intense  pain  produced  by  the  action  of  the  chloride. 

5.  After  another  interval  of  five  days,  the  cotton  wool  containing  the  caustic  is  removed. 
A  cup-shaped  greyish  slough  will  be  found  under  it  and  is  easily  taken  away.     The  granu- 
lating surface  beneath  will  cicatrize  in  a  fortnight. 

The  results  of  this  operation  are  said  by  Marion  Sims  to  be  more  satisfactory  than 
those  which  follow  from  the  use  of  the  knife  with  healing  by  the  first  intention.  He 
mentions  one  case  in  which  he  removed  an  epithelioma  of  the  anterior  lip  (represented  in 
fig.  292)  the  size  of  a  Sicily  orange.  A  year  afterwards  the  operation  had  to  be  repeated 
to  remove  a  similar  tumour  from  the  posterior  lip.  Five  years  after  this  the  patient  was 
still  in  good  health,  though  smaller  growths  had  been  removed  in  the  interval. 

Van  de  Warker  has  recorded  three  interesting  cases  treated  by  this  method.  He  uses 
a  stronger  solution  (equal  parts  by  weight)  of  the  chloride  of  zinc  and  a  30  per  cent,  solu- 
tion of  the  bicarbonate  with  an  ointment  (1  part  bicarbonate  to  three  parts  vaseline)  to 
protect  the  genitals. 

Frankel1  has  tried  this  method  in  six  cases  which  were  considered  inoperable,  with  the 
result  that  all  were  free  for  a  longer  or  shorter  period — one  being  without  recurrence 
after  seven  years.  After  scraping  and  applying  the  actual  cautery,  he  packs  with  iodo- 
form  gauze  until  the  slough  has  separated ;  and  then  applies  the  chloride-of-zinc  solution 
but  leaves  it  on  for  only  twelve  to  twenty-four  hours  at  a  time.  The  greyish  leathery 
slough  comes  away  in  eight  to  ten  days,  and  then  dry  iodoform -gauze  packing  is  used  again 
until  the  surface  has  healed. 

Schramm2  injects  occasionally  a  solution  of  corrosive  sublimate  into  the  cancer-mass 
with  the  result  that  the  discharge  is  lessened  and  the  degenerative  process  is  retarded. 
Scharlaus 3  used  chromic  acid  to  destroy  recurrent  growths  after  amputation ;  and  the 
patient  was  well  four  years  afterwards,  having  had  a  child  in  the  interval. 


EXCISION  OF  THE  WHOLE  UTERUS. 

Freund's  To  Freund  of  Strassburg  is  due  the  credit  of  having  first  thought 
Operation.  Qu£  an(j  carrje(j  jn^o  execution  a  method  by  which  the  whole  uterus  can 
be  removed.  This  method  has  increased  the  possibility  of  a  radical 
cure  of  malignant  disease  of  the  uterus,  though  the  number  of  cases 
suitable  for  extirpation  is  more  limited  than  we  should  have  supposed. 
The  uterus  alone  can  be  removed  by  it,  not  the  glands  or  connective 
tissue  in  the  pelvis  to  which  the  disease  in  the  majority  of  cases  soon 
spreads.  But  when  the  disease  has  originated  in  the  body  of  the  uterus, 
or  beginning  at  the  cervix  has  extended  upwards  into  the  uterus  rather 
than  into  the  vagina  or  the  connective  tissue,  the  extirpation  of  the 
uterus  holds  out  the  prospect  of  a  radical  cure.  This  may  be  done 

A.  By  abdominal  incision, 

B.  Through  the  vagina.4 

Freund's         A.  BY  ABDOMINAL  INCISION  (Freund's  method).      As  the  high  mor- 
Method.     tality  from  this  method  (72  per  cent.)  has  made  most  operators  abandon 

1  Centralb.f.  Gyn.,  Bd.  XII.,  S.  593. 

2  Centralb.f.  Gyn.  Bd.  XII.,  S.  213.  3  Beitrage  zur  Geburts.  Berlin.,  Bd.  II.,  S.  23. 

4  A  third  method,  which  is  a  combination  of  these,  has  been  so  seldom  used  that  it  requires  no  notice 
here. 


CARCINOMA  UTERI:   TREATMENT  OF  DISEASE.     495 

it  for  the  vaginal  method,  we  shall  merely  indicate  in  what  the  operation 

consists. 

The  abdominal  cavity  having  been  opened,  the  uterus  is  laid  hold  of  and  each  broad 
ligament  ligatured  in  three  parts,  the  lowest  ligature  passing  through  the  lateral  fornix 
of  the  vagina.  The  Uterus  is  now  cut  away  from  the  broad  ligaments ;  and  the  knife 
carried  through  the  peritoneum  of  the  utero-vesical  pouch  and  pouch  of  Douglas  into  the 
anterior  and  posterior  fornices  so  that  the  whole  organ  is  thus  excised.  The  ends  of  the 
ligatures  in  the  broad  ligaments  are  brought  through  the  hole  in  the  roof  of  the  vagina, 
in  which  a  drainage  tube  is  also  placed. 

The  results  of  this  method  of  extirpation  are  according  to  Gusserow  148  cases  with  a 
mortality  of  71 '6  per  cent.,  according  to  Duncan  137  cases  with  a  mortality  of  72  per 
cent. l 

B.  EXTIRPATION  THROUGH  THE  VAGINA.  Different  operators  have 
introduced  various  modifications,  but  these  are  only  in  detail.  We 
describe  the  operation  as  performed  by  Martin. 


FIG.  293. 

VAGINAL  EXTIRPATION  of  THE  UTERUS  (Martin). 

The  cervix  has  been  drawn  downwards  with  forceps,  the  pouch  of  Douglas  opened  transversely,  and 
row  of  sutures  passed  through  vaginal  fornix  and  peritoneum. 

1.  Place  patient  in  lithotomy  posture,  empty  bladder  and  thoroughly 
disinfect  genital   tract.      Let   assistants   hold   anterior   and   posterior 
vaginal  specula  and  lateral  retractors  in  position,  draw  down  cervix 
with  volsella  and  direct  it  forwards  towards  pubes.     Make  a  transverse 
incision  through  the  junction  of  vaginal  mucous  membrane  with  posterior 
surface  of  cervix.     The  pouch  of  Douglas  is  thus  opened.     Then  sew 
the  peritoneum  and  vaginal  mucous  membrane  together  by  three  or 
four  sutures  parallel  to  line  of  incision  and  slightly  behind  it  (fig.  293). 

2.  Pass  left  index  finger  into  pouch  of  Douglas  and  press  left  broad 

1  Several  cases  of  total  extirpation  of  the  pregnant  cancerous  uterus  are  on  record.  Sir  Spencer 
Wells  in  1881  and  Zweifel  in  1888  removed  one  at  sixth  month,  patients  recovering  in  both  cases. 
Schroeder  operated  at  full-time  in  two  cases,  and  Bischoff  in  one.  All  three  died. 


496  AFFECTIONS  OF   UTERUS. 

ligament  down  against  vaginal  roof.  With  a  large  curved  needle  pass 
a  suture  through  anterior  part  of  left  lateral  fornix,  through  broad 
ligament  above  uterine  artery,  and  out  again  through  the  vaginal  roof 
close  to  the  outermost  suture  of  the  posterior  row  (fig.  294).  Pass  a 
ligature  in  the  same  manner,  also,  on  the  right  side.  Then  with  scissors 
cut  through  the  bases  of  the  broad  ligaments  as  high  as  ligatures  reach, 
keeping  close  to  uterus. 

3.  Draw  cervix  backwards,  and  at  the  line  of  junction  of  vaginal 
mucous  membrane  with  its  anterior  surface,  make  a  transverse  incision 
down  to  muscular  substance  of  uterus.  Carefully  separate  bladder 
from  uterus  and  open  into  utero-vesical  pouch  of  peritoneum.  Bring 
vaginal  mucous  membrane  and  peritoneum  into  close  apposition  by  a 
transverse  row  of  sutures  applied  as  was  done  posteriorly. 


FIG.  294. 

VAGINAL  EXTIRPATION  OF  UTERUS  (Martin). 
Application  of  first  ligature  in  lateral  fornix  to  control  vessels  in  base  of  broad  ligament. 

4.  With  volsella  pull  down  fundus  through  pouch  of  Douglas  as  far  as 
possible.     The  broad  ligaments,  and  generally  the  tubes  and  ovaries, 
are  thus  brought  into  vagina. 

5.  Now  ligature  broad  ligaments   above   the   level   of  the   uterine 
arteries.     This  is  done  by  two  or  three  sutures  passed  exactly  as  in  the 
case  of  that  first  applied  in  the  lateral  fornix,  only  at  successively  higher 
levels  in  the  vaginal  roof.     The  uterus  is  then  cut  away,  the  tubes  and 
ovaries  being  also  removed  when  possible. 

Thus  the  sutures  are  all  tied  on  the  vaginal  surface,  and  they  approxi- 
mate the  serous  surfaces  of  broad  ligaments  and  pelvic  floor  to  one 
another  as  well  as  to  the  vaginal  mucous  membrane. 

If  a  wide  opening  remains,  it  can  be  made  smaller  by  a  suture  on 


CARCINOMA  UTERI:   TREATMENT  OF  DISEASE.     497 

each  side.     A  rubber  drainage-tube  may  be  used  or  not.     Dust  wound 
with  iodoform  and  place  an  iodoform-gauze  tampon  in  vagina. 

Czerny  brings  down  fundus  through  opened-up  utero-vesical  pouch.  Olshausen, 
Leopold  and  others  do  not  draw  fundus  clown,  but  gradually  cut  away  uterus  from 
broad  ligaments  after  suturing  the  latter  in  successive  stages  from  below  upwards. 

Fritsch  operates  in  the  same  way,  but  ligatures  the  uterine  arteries  and  cuts  through 
base  of  broad  ligaments  before  opening  into  peritoneum.  Richelot,  Pean,  and  others  do 
not  ligature  the  broad  ligaments  but  apply  a  clamp  to  each  one,  which  is  removed  in 
about  forty-eight  hours. 

The  mortality  from  the  operation  of  total  extirpation  (including  cases 
other  than  cancer)  is  given  by  Martin  as  16 '6  °/o  in  134  cases,  by 
Hofmeier  and  Schroeder  as  16*2  °/o  in  74  cases,  by  Fritsch  as  10  °/o  in 
60  cases,  by  Leopold  as  6'2  °/o  in  48  cases,  by  Staude  as  4*54  °/0  m  22 
cases,  and  by  Sanger  as  8 '3  °/o. 


COMPARISON    OP    THE    RESULTS    OF    AMPUTATION    OF    THE    CERVIX    WITH 
THOSE    OF   EXTIRPATION    OF    THE    UTERUS. 

In  judging  of  the  relative  merits  of  these  operations,  we  must  take 
into  account  (1)  the  immediate  result  with  regard  to  recovery  from  the 
operation,  and  (2)  the  ultimate  result  with  regard  to  the  non-recurrence 
of  the  disease. 

(1.)  The  immediate  result. 

The  mortality  for  amputation  of  the  cervix  with  the  Galvano-cautery 
is  7^  °/0  (Pawlik's  statistics,  v.  p.  491) ;  with  the  knife,  in  33  cases  of 
Gusserow's  9'09  °/o,  and  in  136  cases  of  Schroeder  and  Hofmeier's  7'4  °/0. 

We  have  seen,  however,  that  although  Schroeder's  mortality  in  total 
extirpation  was  greater  than  in  partial  amputation,  later  operators  have 
gradually  reduced  the  death-rate  in  the  major  operation  to  as  low  a 
figure  as  5  or  6  °/o. 

(2.)  The  ultimate  result. 

(a.)  In  amputation  of  the  cervix. 


BRAUN  (PAWLIK). 
(Galvano-  Caustic) 

SCHROEDER  (HOFMEIER). 
(High  Amputation) 

136  Cases. 

115  Cases. 

Died  after  operation 
Known  to  be  free  1  year  afterwards 

10 
33 

18 
50 

2 

26 

40 

3 

— 

28 

4 

— 

21 

5 

— 

11 

6 

—  . 

5 

12 

2 

— 

19£ 

1 

Of  the  cases  not  accounted  for  by  this  table,  some  had  a  return,  while  others  were  not 
followed  up. 
2  i 


498 


AFFECTIONS   OF   UTERUS. 


(b.)  In  total  extirpation. 

Post l  of  New  York  has  collected  over  700  cases  performed  before  the 
end  of  1887,  in  which  the  total  death-rate  was  24  °/o. 
The  results  of  the  leading  operators  are  as  follows  : — 


Martin 

Fritsch 

Leopold 

Schroeder-Hofmeier 

(1887). 

(1886). 

(1887). 

(1886). 

Of  44  cases  in  years 

Of  53  cases  in  years 

Of  37  cases  in  years 

Of  46  cases  in  years 

1880-85,  disease  had 

1883-86,  disease  had  1883-87,  disease  had 

1878-85,     33     were 

returned  in  13  (297 

not    returned  in  20  retiirned  in  8  (21  7=) 

watched  for  1  year, 

V.)  by  1887. 

(37-7%),  10  months  within   1   year.      Of 

and     of     these     13 

afterwards.          Two  the  rest  only  18  were 

(36-4  "/.)  had  return 

cases  had  been  free 

heard  from  ;  and  of 

of  disease  ;   23  were 

for    3    years,    seven  these  12  had  had  no 

watched  for  3  years, 

for    2-3    years,    and  return  for  1-2  years, 

of  whom  17  (74  °L) 

eight  for  1-2  years. 

and  6  for  2-3^  years. 

had  return  ;   and  10 

The  others  had  not 

for   4    years,   all  of 

been  followed. 

whom    had    return. 

The  other  cases  were 

not  followed. 

Terrier  of  Paris  reports  11  cases  operated  on  in  1885.     Of  these,  4  were  well  after 

2  years.     The  others  had  had  a  return  within  16  months. 

Taking  the  total  and  partial  operations  together,  we  find  that  Schroeder 
and  Hofmeier  have  given  immunity  for  at  least  four  years  to  one-third 
of  their  patients.  The  results  as  regards  recurrence  are  not  nearly  so 
good  with  total  extirpation  as  with  partial  amputation,  yet  it  must  not 
be  concluded  that  the  former  operation  favours  a  return.  In  all  cases 
in  which  the  cancer  was  removed  by  partial  amputation,  total  extir- 
pation also  would  certainly  have  removed  it  and  with  (as  is  now  estab- 
lished) as  small  a  death-rate.  The  above-mentioned  cases  of  partial 
operation  must  have  been  particularly  favourable  ones  i.e.,  in  which  the 
disease  was  distinctly  localised  and  in  an  early  stage  of  growth.  In  all 
such  cases,  the  minor  operation  will  be  preferred.  The  great  majority 
of  cases,  unfortunately,  are  operated  upon  when  the  disease  has  existed 
for  some  time  and  when  there  is  uncertainty  as  to  whether  it  has  spread 
beyond  the  uterus  even  though  that  be  not  demonstrable  by  manual 
examination.  It  is  evident,  therefore,  that  in  these  cases,  until  we  are 
able  to  diagnose  more  correctly,  we  shall  operate  in  many  cases  where  a 
return  is  certain. 

Although  women  themselves  often  put  off  consulting  a  medical  man 
owing  to  the  slight  disturbance  caused  by  cancer  in  its  early  stage, 
there  are  many  cases  in  which  through  ignorance  or  carelessness  the 
practitioner  allows  the  disease  to  advance  until  its  exact  limits  can  no 
longer  be  denned. 

The  character  of  the  cancer  must  be  taken  into  account  in  the  prog- 
nosis as  to  the  ultimate  results ;  an  extensive  papillary  cancroid  of  the 
vaginal  portion  giving  the  worst  prognosis ;  cancer  of  the  cervix  a 
relatively  better,  and  cancer  of  the  vaginal  portion  the  best. 

1  Am.  Jotirn.  Obst.,  Nov.  1SS7. 


CARCINOMA  UTERI:   TREATMENT  OF  DISEASE.     499 

Comparison  Letiveen  Cancer  of  the  Uterus  and  the  disease  elsewhere,  as 
regards  operative  treatment. 

Fritsch  finds  that  recurrence  after  removal  by  total  extirpation  is  less 
frequent  than  after  similar  removal  from  any  other  part  of  the  body. 
He  gives  Von  Volkrnann's  statistics  of  Cancer  of  the  breast  as  follows  : — 

Out  of  131  cases,  return  of  the  disease  was  observed 

In  1  month  in  7  cases, 
2-6        „       ,,23      „ 
7-12  12 

1      •L>J  J)  ))   *~          v> 

13-18  ,,  „  5  ,, 
19-24  „  „  6  „ 
25-36  1 


CHAPTER    XLIII. 

CARCINOMA  OF  THE  BODY  OF  THE  UTERUS. 

LITERA  TURS. 

Brcisky  and  Eppinger — Prager  med.  Wochenschrift,  S.  78,  1877.  Gusserow — Neubil- 
dungen  des  Uterus,  S.  254  :  Stuttgart,  1885.  Schrocdcr—Die  Krankheiten  der  weib- 
lichen  Geschlechtsorgane,  S.  295.  Simpson,  Sir  J.  Y. — Selected  Obstetrical  and 
Gynecological  Memoirs,  edited  by  Watt  Black,  p.  769.  Veit — Zeitschrift.  fur 
Geburts.  und  Gyn.,  Bd.  I.,  S.  467.  Zur  Kenntniss  des  Carcinoma  corporis  uteri: 
Centralb.  f.  Gyn.,  Bd.  X.,  S.  173. 

PATHOLOGY   AND   ETIOLOGY. 

CARCINOMA  affects  the  body  of  the  uterus  much  more  rarely  than  the 
cervix;  in  only  13  out  of  686  cases  of  uterine  cancer,  that  is  in  rather 


FIG.  295. 

UTEKUS  EXTIRPATED  FOR  CANCER  ;  no  recurrence  five  years  after  operation  (Hofmeier). 

less  than  2  per  cent,  was  the  disease  situated  in  the  body  of  the  uterus 
(Schroeder). 

Its  rarity  is  apparent  from  the  fact  that  Gusserow,  after  a  careful 
survey  of  the  whole  literature,  has  collected  but  80  cases. 

As  in  the  cervix,  the  disease  originates  either  in  the  substance  of  the 


CARCINOMA  OF  THE  BODY  OF  THE  UTERUS.       501 

walls  of  the  uterus  or  in  the  mucous  membrane.  In  the  former  case,  it 
begins  as  localised  nodules  which  grow  rapidly  and  produce  bulging  of 
the  mucous  membrane  or  of  the  peritoneal  coat  but  do  not  tend  to 
ulcerate.  When  in  the  mucous  membrane,  it  causes  a  uniform  swelling 
(fig.  295)  or,  more  usually,  projects  in  polypoidal  masses  (fig.  296).  Fig. 
295  from  Hofmeier,  shows  a  uterus  extirpated  for  cancer;  the  disease 
had  not  recurred  within  five  years  after  the  operation. 

By  Eppinger  and  Huge  the  disease  has  been  directly  traced  to  the 
epithelium  of  the  uterine  glands  ;  these  first  hypertrophy,  and  then  their 
proliferating  epithelium  passes  into  carcinomatous  epithelial  cells.  The 
new- formation  ulcerates,  so  that  the  wall  of  the  uterus  becomes  con- 
verted into  an  excavated  surface  with  a  hard  base.  Adhesions  rapidly 


FIG.  296. 

CARCINOMA  OF  THE  BODY  OF  THE  UTERUS.    The  uterine  cavity  is  increased  in  size  but  the  cervix 
is  undilated  (Sir  J.  Y.  Simpson). 

form  with  neighbouring  organs,  while  secondary  deposits  may  develop 
in  the  peritoneal  cavity. 

As  to  Etiology,  what  has  been  said  of  carcinoma  of  the  cervix  applies 
here  with  two  additional  facts.  (1)  It  occurs  rather  later  in  life  than 
cancer  of  the  cervix;  and  (2)  is  more  frequent  in  nulliparse.1 

SYMPTOMS   AND    DIAGNOSIS. 

Again,  as  in  carcinoma  of  the  cervix,  the  symptoms  are  pain,  haemor- 
rhage, and  foetid  discharge.     1.  Pain,  in  contrast  with  carcinoma  of  the  Pain, 
cervix,  is  always  an  early  symptom.     Sir  J.  Y.  Simpson  drew  attention 

1  Taking  Veit's  two  series  of  cases  together,  we  have  out  of  80  cases,  31  between  50  and  60  and  21 
above  60  years  of  age  (cf.  table  in  fig.  283)  ;  and  of  72  cases,  38  were  childless. 


502  AFFECTIONS  OF  UTERUS. 

to  periodic  attacks  of  severe  pain  as  characteristic  of  cancer  of  the  body. 

This  is  not  always  present  and  is  probably  due  to  \iterine  contractions 

Haemor-      set  Up  by  accumulation  of  secretion  (Veit}.     2.    HcemorrJiage   is  also 

present  at  an  early  stage ;  it  takes  the  form  of  profuse  menorrhagia, 

because  the  mucous  membrane  from  which   the  menstrual  flow  takes 

Discharge.  place  is  diseased.     3.  The  discharge  is  usually  profuse  and  becomes  after 

a  time  foetid.     Sometimes  it  is  watery  and  not  offensive ;  rarely  is  it 

altogether  absent. 

On  vaginal  examination,  the  cervix  is  found  to  be  either  normal 
(fig.  296)  or  dilated.  The  uterus  is  enlarged,  and  may  be  freely  movable 
or  may  be  fixed  by  adhesions.  The  sound  shows  the  cavity  to  be  enlarged 
and  may  reveal  irregularity  of  the  mucous  membrane;  its  introduction 
is  followed  by  haemorrhage.  The  condition  of  the  mucous  membrane  is 
more  precisely  ascertained  by  examination  with  the  finger  after  dilatation 
of  the  cervix  with  a  tent.  In  the  majority  of  cases,  certainty  of  diagnosis 
is  possible  only  through  microscopic  examination  of  fragments  removed 
by  the  curette.  Should  these  show  merely  hypertrophied  glands,  we 
must  remember  that  this  is  sometimes  a  transition  stage  to  malignant 
disease.  Typical  carcinomatous  cells  are  seen  at  fig.  285. 

The  Differential  Diagnosis  must  be  made  from — 
Portions  of  retained  placenta, 
Sloughing  submucous  fibroid, 
Haemorrhagic  endometritis. 

These  conditions  have  been  already  described.  As  to  the  first  of 
these  we  note  that  carcinoma  sometimes  develops  during  the  puerperium. 
In  three  cases  observed  by  Chiari,  the  development  of  carcinoma  was 
directly  connected  with  the  puerperium  and  ran  a  rapid  course  to  a  fatal 
termination  within  six  months  after  the  birth  of  the  child. 

During  the  period  of  sexual  activity,  differential  diagnosis  is  often 
extremely  difficult ;  rapid  growth  and  development  of  peritonitis  fixing 
the  uterus,  point  to  malignant  disease.  After  the  menopause,  the 
recurrence  of  haemorrhage  is  an  important  diagnostic.  The  microscope 
is,  when  available,  the  most  reliable  guide. 

TREATMENT. 

As  to  the  treatment  of  the  symptoms,  this  is  the  same  as  in  Carcinoma 
of  the  Cervix  (v.  Chap.  XLIL).  As  to  the  treatment  of  the  disease,  the 
scraping  away  of  the  polypoidal  masses  with  the  curette  or  sharp  spoon 
gives  temporary  relief  from  the  haemorrhage  and  discharge.  The  only 
hope  of  cure  lies  in  extirpation  of  the  uterus  (v.  p.  494).  * 

1  Of  7  cases  (1  by  Schroeder)  done  by  Veit,  1  died  after  operation  ;  and  of  4  cases  followed,  1  had 
recurrence  in  first  year,  2  in  second,  and  1  not  after  three  years. 


CHAPTER  XLIV. 

SARCOMA  UTERI. 

'LITERATURE. 

Chroback — Beitrag  zur  Kenntniss  des  Uterussarkoms :  Arhiv  f.  Gyn.,  Bd.  IV.,  S.  549. 
Clay,  J. — On  diffuse  Sarcoma  of  the  Uterus  :  Lancet,  Jan.  1887.  Galabin — Lond. 
Obst.  Trans.,  Vol.  XX.  Gusscrow—  Die  Neubildungen  des  Uterus,  S.  158:  Stutt- 
gart, 1885.  Jacubash — Vier  Falle  von  Uterussarcom  :  Zeitschrift  f.  Geburts.  u.  Gyn., 
Bd.  VII.,  Hft.  I.  Kunert— Ueber  Sarcoma  Uteri :  Arch.  f.  Gyn.,  Bd.  VI.,  S.  29. 
Rogivue — Du  Sarcome  de  1'uterus  :  Inaug.  dissert.,  Zurich  1876.  Schroeder — Die 
Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  320 :  Leipsic,  1886.  Simpson, 
A.  R. — Contributions  to  Obstetrics  and  Gynecology,  p.  240 :  Edin.,  1880.  Spiegel- 
berg — Sarcoma  Colli  Uteri  hydropicum  papillare  :  Archiv  f.  Gyn.,  Bd.  XIV.,  S.  178. 
Bin  weiterer  Fall :  Ibid.,  Bd.  XV.,  S.  437.  Thomas— Diseases  of  "Women,  p.  566, 
Lond.  1880  ;  and  Sarcoma  of  the  Uterus,  Lond.  Obst.  Jourii.,  Vol.  II.,  1875,  p.  437. 
Virchow — Die  Krankhaften  Geschwulste  :  Bd.  II.,  S.  350.  Winkler — Ein  weiterer 
Fall  von  Sarcoma  papillare  hydropicum  cervicis  et  vaginae :  Archiv  f.  Gyn.,  Bd. 
XXI.,  S.  309.  For  a  full  resume  of  the  earlier  literature,  see  Gusserow  and  A.  R. 
Simpson  ;  and,  for  recent  literature,  the  Index  in  the  Appendix. 

BY  sarcoma  we  understand  a  connective-tissue  tumour  of  an  embryonic  Nature  of 
type.     As  we  trace  back  carcinoma  to  the  epithelium  and  true  myoma      coma" 
to  the   muscular  fibre,  so  we   trace   back   sarcoma  to  the   connective 
tissue. 

For  the  recognition  of  sarcomata  as  of  connective-tissue  origin  and 
the  limitation  of  the  term  to  malignant  tumours  of  this  type,  we  are 
indebted  to  Virchow.  Formerly  they  were  known  in  English  literature 
as  "  recurrent  fibroids  ; "  the  existence  of  this  form  of  tumour  in  the 
uterus  was  recognised  and  fully  described  by  Hutchinson  (1857). 

PATHOLOGY. 

Unlike  carcinoma,  sarcoma  rarely  occurs  in  the  cervix ;  in  the  larger 
proportion  of  cases  it  is  in  the  body  of  the  uterus. 
It  occurs  in  two  forms  : — 

1.  Diffuse  sarcoma  of  the  mucous  membrane ; 

2.  Circumscribed  fibrous  sarcoma, 

The    diffuse    sarcoma  of  the  mucous   membrane   arises  from  the  sub- Diffuse 
epithelial  connective  tissiie.      It  appears  as  a  general  swelling  of  the 
mucous   membrane    which  becomes   soft  and  crumbly,  or  as  irregular 
foldings  or  knobby  projections  into  the  uterine  cavity ;  sometimes  these 


504 


AFFECTIONS  OF  UTERUS. 


projections  have  a  polypoidal  and  apparently  circumscribed  character 
(fig.  297)  so  that  this  form  passes  insensibly  into  the  fibrous.  The 
masses  have  a  greyish-white  brain-like  appearance,  and  soft  pulpy  con- 
sistence. The  mucous  membrane  may  be  broken  down  but  is  not 
deeply  excavated  as  in  carcinoma.  On  microscopic  examination  the 
mucous  membrane  is  seen  to  be  infiltrated  with  masses  of  closely-set 


FIG.  297. 

SARCOMA  UTERI  WITH  TUMOURS  IN  THE  VAGINA — from  a  specimen  in  the  Pathological  Institute  at 

Strassburg  (Gusseroie). 

round    cells,    more    rarely    spindle-cells.      Epithelial-cell    proliferation 
often  complicates  this  form  of  sarcoma  and  brings  it  into  close  relation 
to    carcinoma.      Klebs    has    proposed    to    call    such    forms    carcino- 
sarcomata. 
Sarcoma.        The  circumscribed  ftbro-sarcoma  arises  in  the  muscular  coat ;  like  the 


SARCOMA    UTERI. 


505 


fibroid  it  may  be  submucous,  interstitial,  or  sub-peritoneal,  and  is  found 
usually  in  the  body,  rarely  in  the  cervix.  The  tumours  are  of  a  firm 
consistence,  and  feel  like  knots  in  the  muscular  wall  of  the  uterus  or 
project  as  polypi  into  its  cavity ;  they  thus  resemble  small  fibroids,  but 


MICROSCOPIC  SECTION  OF  THE  Mucous  MEMBRANE  OF  THE  UTERUS  IN  A  CASE  OF  SARCOMA  (Schroedir). 
S  Sarcomatous  tissue  ;  c  small-celled  infiltration  ;  g  uterine  glands. 

have  no  capsule.     Microscopically  they  consist  of  a  localised  sarcomatous 
— generally  round-celled — infiltration  (fig.  298). 

In  some  cases  it  has  been  alleged  that  sarcoma  is  a  degeneration  of  a 
fibroid  tumour^  as  in  the  following  specimen  described  by  A.  R.  Simpson. 
"  On  section  it  presented  a  uniformly  smooth  surface  of  pale-pinkish 


FIG.  299. 

SARCOMA  UTERI,  seen  on  section,  showing  fibroid  nodules  (A.  R.  Simpson). 

colour,  with  some  islands  in  it  presenting  the  familiar  cotton-ball  struc- 
ture and  clear  white  glistening  aspect  seen  on  section  of  an  ordinary 
fibroid  tumour  of  the  uterus,  and  separated  from  the  softer  surrounding- 
tissue  by  a  connective-tissue  capsule  (fig.  299).  The  larger  part  of  the 
tumour  was  composed  of  fusiform  nucleated  cells,  with  an  intercellular 


506 


AFFECTIONS   OF   UTERUS. 


matrix  having  a  fibrillated  appearance,  and  running  for  the  most  part  in 
small  sections  in  parallel  directions."  A  portion  of  the  tumour,  probably 
then  a  fibro-myoma,  had  been  removed  five  years  previous  to  this ;  a 
third  portion  of  the  tumour,  removed  four  years  subsequent  to  this, 
showed  only  sarcomatous  tissue.  A  similar  case  is  reported  by  Ballan- 
tyne,  with  microscopic  sections.  *  Chroback  and  Miiller  "  also  have 
traced  the  development  of  sarcoma  in  tumours  which  were  originally 
undoubted  fibroids.  There  is  therefore  no  doubt  that  this  is  one  mode 
of  origin  of  fibro-sarcoma ;  whether  (as  Schroeder  and  Kunert  have 
suggested)  this  is  always  the  origin,  is  as  yet  undecided. 

Secondary  nodules  may  form  in  the  vagina  (fig.  297)  and  peritoneal 
cavity.  Sometimes  the  peritoneum  is  affected  by  continuous  spreading 
of  the  new  growth  outwards  towards  the  peritoneal  covering ;  here  it 


Co-exist- 
ence of 
Inversion 
of  Uterus. 


FIG.  300. 

SARCOMA  UTERI  INVADING  THE  FALLOPIAN  TUBES  and  projecting  from  their  fimbriated  ends 
(A.  R.  Simpson). 

causes  adhesions,  through  which  the  sarcomatous  infiltration  may 
extend  to  other  organs  (Gusserow).  A.  R.  Simpson  records  a  unique 
case  in  which  the  infiltration  spread  along  the  mucous  membrane  of  the 
Fallopian  tubes  (fig.  300),  so  that  from  their  fimbriated  ends  there  pro- 
jected "  rounded  masses,  having  the  appearance  of  the  thrombus  project- 
ing from  a  small  vein  into  a  larger  trunk."  The  uterus  was  of  the  size 
of  a  four-months'  pregnancy. 

A.  R.  Simpson  draws  attention  to  the  frequency  of  inversion  of  the 
uterus  as  the  result  of  sarcoma.     We  referred  to  it  as  a  rare  complica- 

1  Edin.  Med.  Jour.,  Nov.  1884. 
2  Zur  operativen  Behandlung  der  Uterusmyome  :  Archiv  /.  Gyn.,  Bd.  VI.,  S.  125. 


SARCOMA    UTERI.  507 

tion  of  pediculated  subucmous  fibroid  tumours.  In  sarcoma,  it  appears 
to  occur  more  frequently — in  4  out  of  48  cases.  He  attributes  this  to 
the  paralysis  of  the  muscxilar  Avail  of  the  uterus  through  sarcomatous 
infiltration  and  to  the  peculiar  dilatability  of  the  cervix  observed  in 
some  cases. 

Sarcoma  of  the  cervix  is  rare  ;  in  Winkler's  paper,  eight  cases  are  referred  Sarcoma  of 
to  besides  his  own.  Two  of  these  were  spindle-celled,  the  rest  round- 
celled  sarcoma.  A  special  form  has  been  described  as  Sarcoma  papillare 
hydropicum  cervicis.  It  grows  as  a  papillary  tximour  which  fills  the 
vagina  and  may  project  outside  the  vulva.  The  cells  are  embedded  in 
an  abundant  intercellular  substance  which  stains  faintly,  is  granular 
and  traversed  by  delicate  thi-eads.  It  has  been  erroneously  described 
as  a  myxo-sarcoma ;  in  Spiegelberg's  cases,  it  was  shown  that  this  inter- 
cellular substance  was  not  mucin  but  coagulated  lymph. 

Large  vascular  spaces  may  form  in  their  substance — as  occurs  in 
fibroid  tumours ;  in  a  case  recorded  by  Jacubash,  the  bursting  of  such 
a  vascular  tumour  into  the  peritoneal  cavity  proved  suddenly  fatal. 

Metastatic  deposits,  though  rare,  are  found  more  frequently  in  fibro-  Metastatic 
sarcoma  than  in  diffuse  spreading  sarcoma.     They  have  been  found  in    eposl  s' 
the  lymphatic  glands,  lungs,  liver  and  vertebrae. 

ETIOLOGY   AND    FREQUENCY. 

Of  the  reason  why  a  source  of  irritation  should  lead  the  connective  tissue 
to  produce  a  sarcomatous  new-formation,  we  know  as  little  as  why  the  same 
cause  produces  a  carcinomatous  new-formation  from  the  epithelium. 

As  to  its  frequency,  a  sufficient  number  of  cases  has  not  yet  been  Frequency, 
collected  to  form  any  generalisation.     It  is,  however,  so  rare  that  every 
carefully  observed  case  which  has  been  authenticated  by  microscopic 
examination  should  be  placed  on  record.     Gusserow  has  collected  only 
73  cases. 

Age  has  the  same  predisposing  influence  as  in  fibroma  and  carcinoma.  Influence 
Adding  to  Gusserow's  cases,  8  which  we  have  collected  from  the  litera-0 
ture  of  the  last  three  years  we  find  that 

4  were    under    20, 

5  „  between  20  and  30, 
17  „  „   30  „  40, 
31  „  „   40  „  50, 
19  „  „   50  „  60, 

4  „     „   60  „  70, 

1  was  above  70. 

The  number  of  sterile  patients  among  those  affected  with  sarcoma  (25  Sterility 
out  of  63)  is  noteworthy ;  in  this  respect  it  contrasts  with  carcinoma1 
(Gusserou'). 

1  In  74  cases  of  sarcoma,  25  were  sterile,  and  16  had  less  than  3  children. 


508  AFFECTIONS  OF   UTERUS. 

SYMPTOMS. 

The  following  conditions  characterise  the  early  stage,  in  which  the 
patient  seeks  advice  : — 

1.  Haemorrhage, 

2.  Absence  of  pain, 

3.  Watery  non-offensive  discharge, 

4.  Cachexia. 

Haemor-          Haemorrhage  appears  first  as  increase  of  the  menstrual  flow,  or  as 

r  iage-  irregular  haemorrhages  after  the  menopause.  As  the  new-formation  does 
not  ulcerate  rapidly  like  carcinoma,  the  increased  menstruation  is  due  to 
hypersemia  of  the  mucous  membrane  (Clay}. 

Pain.  The  absence  of  pain  in  the  early  stage  is  remarked  on  by  Clay  and 

A.  R.  Simpson;  in  this  respect  it  differs  from  intra-uterine  cancer. 
According  to  Gusserow,  on  the  other  hand,  pain  is  frequently  present 
and  that  of  an  intense  and  rending  character.  This  apparent  discre- 
pancy of  opinion  may  be  explained  by  the  varying  progress  of  the 
infiltration.  In  the  spreading  of  carcinoma,  we  noted  that  pain  was 
most  severe  when  the  disease  was  extending  upwards  and  compressing 
the  nerve  endings  in  the  uterus  and  connective  tissue. 

Discharge.  The  free  rice-watery  discharge  has  a  slight  odour  but  is  not  nearly  so 
offensive  as  in  carcinoma ;  this  is  due  to  the  fact  that  there  is  not  the 
same  rapid  ulceration  and  necrosis  of  tissue.  When  the  disease  has 
progressed  further,  the  discharge  becomes  equally  foetid.  The  presence 
in  the  discharge  of  greyish-ivhite  shreds,  like  particles  of  brain  matter, 
is  diagnostic  ;  under  the  microscope  these  are  seen  to  consist  of  small 
portions  of  sarcomatous  tissue. 

Cachexia.  Cachexia  is  of  importance  as  it  helps  us  to  distinguish  developing 
sarcoma  from  a  non-malignant  polypus ;  the  drain  from  the  latter  may 
make  the  patient  gradually  anaemic  ;  but  there  are  not  the  loss  of  flesh, 
the  loss  of  appetite  and  the  rapid  failure  of  strength,  which  point  to 
malignant  disease. 

DIAGNOSIS. 

If  the  tumour  projects  through  the  os,  the  diagnosis  is  not  difficult. 
The  age  of  the  patient  with  the  symptoms  given  above  and  the  existence 
of  a  soft  friable  pediculated  tumour  which  springs  from  the  body  of  the 
uterus,  will  point  to  the  diagnosis ;  a  portion,  detached  with  the  nail, 
shows  the  characteristic  microscopical  structure.  When  nothing 
projects  through  the  cervical  canal,  we  try  to  dilate  it  with  the  finger, 
or,  if  this  fails,  with  a  sponge  tent  or  the  rapid  method  described  at 
p.  458.  The  finger  recognises  a  soft  friable  condition  of  the  mucous 
membrane,  or  a  distinct  polypoidal  tumour,  or  a  localised  thickening 
in  the  walls. 


SARCOMA    UTERI. 


509 


The  uterus  is  in  some  cases  distinctly  enlarged  and  may  reach  half- 
way to  the  umbilicus  or  lie  retroverted ;  in  the  early  stages  it  is  movable, 
but  it  soon  becomes  fixed. 

The  sound  shows  the  cavity  to  be  enlarged ;  its  use  causes  haemor- 
rhage. 

The   differential    diagnosis    is    here    often    very    difficult,    as    these  Differen- 
conditions  are  also  present  in — 


tial  Diag- 
nosis. 


Chronic  endometritis  (hsemorrhagic  type), 
Small  fibroid  tumours  (interstitial  or  polypoidal), 
Carcinoma. 

Curetting  the  surface,  with  microscopic  examination  of  the  scrapings, 
will  help  us  in  the  first  case. 


FIG.  301. 

CRAPINGS   FROM   A   FlBROID   TUMOUR  to  show  the 

size  and  form  of  the  muscular  fibre,  their  rod- 
shaped  nuclei — stained,  2fu ;  drawn  by  S. 
Delepine. 


FIG.  302. 

SCRAPINGS  FROM  A  SPINDLE-CELLED  SARCOMA  to 
show  the  larger  size  of  the  spindle  cells  and 
their  oval  nuclei — stained,  2 p ;  drawn  by  S. 
Delepine. 


The  removal  of  the  polypoidal  mass,  with  the  finger  nail  or  nail- 
curette,  will  enable  us  to  examine  its  nature ;  the  possibility  of  both 
conditions  being  present,  polypoidal  fibroid  +  commencing  sarcomatous 
degeneration,  must  be  remembered.  With  an  interstitial  thickening, 
we  can  only  watch  the  progress  of  the  case. 

In  carcinoma  of  the  fundus,  there  is  generally  excavation  of  the 
uterine  wall  and  the  base  of  the  ragged  surface  is  harder  than 
in  sarcoma.  The  examination  of  scrapings  is  not  always  decisive, 
as  the  cells  found  in  sarcoma  sometimes  closely  resemble  epithelial 
cells. 

In  all  cases  of  doubt  we  must  watch  for  a  few  months,  when  the 
rapid  growth  of  the  tumour  or  the  development  of  cachexia  will  clear  up 
the  case. 


510  AFFECTIONS   OF  UTERUS. 


PROGNOSIS. 

The  prognosis  is  grave.  Compared  with  carcinoma,  its  development 
is  not  so  rapid  nor  are  the  symptoms  of  pain  and  offensive  discharge  so 
aggravated  in  the  early  stage.  In  two  of  the  cases  recorded  by 
A.  R.  Simpson  the  patient  survived  for  four  years  after  the  diagnosis  of 
sarcoma  was  made  out,  and  Gusserow  mentions  a  case  where  the  course 
was  prolonged  for  ten  years. 

The  temporary  relief  procured  by  removal  is  longer  of  duration  than 
in  carcinoma.  No  case  of  radical  cure  is,  as  far  as  we  know,  recorded ; 
after  removal  it  reappears  at  periods  varying  from  two  to  fourteen  months 
(Clay).  When  it  returns,  the  development  of  the  new  tumour  is  more 
rapid  than  that  of  the  first  growth. 

As  to  the  communication  of  the  prognosis  to  the  patient  and  friends, 
see  under  Carcinoma. 

TREATMENT. 

The  tumour  should  be  removed  as  soon  as  we  suspect  malignancy. 
Even  when  there  is  doubt,  its  removal  will  clear  up  the  case. 

The  cervix  should  be  well  dilated  so  as  to  allow  the  finger  to  pass 
freely  into  the  uterus.  Gradual  dilatation  is  preferable ;  injury  of 
healthy  mucous  membrane  in  dilating  or  curetting  should  be  avoided, 
as  sarcomatous  cells  have  become  engrafted  on  a  fresh  wound  surface. 

When  circumscribed  and  polypoidal,  remove  it  with  the  finger  nail 
or  nail  curette.  After  its  removal  apply  carbolic  acid  thoroughly  to  its 
base. 

When  diffuse,  curette  the  uterus.  Continue  the  scraping  till  all  the 
loose  tissue  and  irregularities  of  the  mucous  membrane  are  removed. 
After  curetting  the  surface  of  the  uterus,  examine  with  the  finger  to 
ensure  that  all  is  removed  and  apply  carbolic  acid  freely.  When  the 
os  is  widely  dilated  and  the  seat  of  the  growth  low  down,  cauterisation 
with  Paquelin's  cautery  would  be  even  more  effectual  Clay  injected 
perchloride  of  iron  after  curetting,  and  without  any  bad  result ;  the 
application  of  the  caustic  on  a  rod  is  safer. 

Extirpation  of  the  uterus  offers  the  only  hope  of  radical  cure 
(v.  p.  494).  Dawson1  has  recorded  a  case  of  extirpation  for  sarcoma  of 
the  cervix. 

1  Anier.Jou.rn.  ObsM.  1SS5,  p.  1184. 


SECTION"    VI. 


AFFECTIONS  OF  THE  VAGINA. 


THESE  we  shall  consider  in  the  following  order  : — 

CHAPTER  XLV.  Atresia  Vaginae. 

,,         XLVI.  Vaginitis  :  Vaginismus  :  Tumours. 


CHAPTER  XLV. 

ATRESIA  VAGINAE. 

LITERATURE. 

Barnes — Diseases  of  Women,  p.  219 :  London,  1881.  Hreisky — Die  Krankheiten  der 
Vagina :  Stuttgart,  1879.  Delaunay — Etude  sur  le  cloisonnement  transversal  du 
Vagin,  etc.  :  Paris,  1877.  Dohrn — Angeborne  Atresia  vaginalis  :  Archiv  fiir 
Gynak.,  Bd.  X.,  S.  3.  Duncan,  J.  Matthews — Case  of  so-called  Imperf  orate  Hymen  : 
Lond.  Obst.  Tr.,  Vol.  XXIV.  Emmet — Principles  and  Practice  of  Gynecology,  p. 
188  :  Philadelphia,  1884.  Congenital  Absence  and  Accidental  Atresia  of  the  Vagina, 
etc.  :  Trans.  Am.  Gyn.  Soc.,  II.,  p.  437.  Fasola— Contribute  allo  studio  dell'origine 
dell'imene,  a  proposito  di  un  caso  di  ematocolpo  per  mancanza  della  parte  inferiore 
della  vagina  e  dell'imene  :  Annal  di  Ostet.,  1885,  p.  146.  Fuld — Salpingotomie 
wegen  Hamatosalpinx  bei  Gynatresie :  Archiv  f.  Gyn.,  Bd.  XXXIV.,  S.  191. 
Leopold — Blutansammlung  im  Verschlossenen  Uterovaginalkanale  und  die  Sal- 
pingotomie :  Archiv  f.  Gyn.,  B.  XXXIV.,  S.  371.  Puech,  A. — Des  Atresies  com- 
plexes des  voies  g^nitales  de  la  Femme  :  Ann.  de  Gynecologie  :  Paris,  1875.  Sirup- 
son,  Sir  J.  Y. — Diseases  of  Women,  p.  256  :  Edin.  1872.  Simpson,  A.  R. — Con- 
tributions to  Obstetrics  and  Gynecology,  p.  195  :  Edin.  1880.  Thomas — Diseases  of 
Women :  London,  1882,  p.  220.  See  Index  of  Recent  Gynecological  Literature  in 
the  Appendix. 

Definition.  ATRESIA  (a-rprjffis,  non-perforation)  has  been  already  defined  as  occlusion 
of  the  genital  tract  where  the  obstruction  is  complete  and  leads  to 
accumulation  of  menstrual  blood  or  mucous  secretion.  This  occurs  at 
three  places — the  hymen,  the  vagina,  and  the  cervix  uteri.  Atresia  of 
the  cervix  has  been  already  described  (v.  Chap.  XXVI.).  Accumulation 
of  blood  in  one-half  of  a  septate  uterus  or  vagina  will  be  considered  by 
itself  at  the  end  of  this  Chapter. 

PATHOLOGY. 

1.  ATRESIA  HYMENALIS. — The  structure  of  the  normal  hymen  has 
been  already  described  (page  6).  In  atresia  hymenalis  it  forms  a  con- 
tinuous membrane,  is  thicker  and  of  an  almost  cartilaginous  toughness ; 
this  explains  the  rarity  of  spontaneous  cure  by  rupture  of  the  membrane. 
This  condition  is  produced  by  the  occurrence  of  inflammatory  adhesion 
of  the  folds  after  their  formation,  that  is  after  the  nineteenth  week  of 
foetal  life.  When  the  vagina  is  distended  with  menstrual  blood,  the 
hymen  bulges  forwards.1  As  the  menstrual  blood  accumulates,  the 
vagina  distends  so  as  to  form  a  tense  membranous-walled  sac  nearly 

1  Blood  extravasation  occurred  into  the  labia  in  Davy's  case.     Lancet,  1880,  II.,  p.  1171. 


AT21ESIA    VAGINAE.  513 

filling  the  pelvis,  and  with  a  smaller  firmer  body  (the  undiluted  uterus) 
rising  from  its  upper  surface  (v.  fig.  305).  If  the  tension  be  not 
relieved,  the  cervix  next  becomes  dilated  and  may  rupture.  Finally  the 
uterus  itself  becomes  opened  out,  though  this  does  not  occur  till  late. 

During  this  period,  accumulations  of  blood  may  take  place  in  the 
Fallopian  tubes  in  the  form  of  diverticula,  usually  situated  towards  the 
fimbriated  end  (figs.  303  and  304).  These  are  not  produced,  as  we 
should  suppose,  by  a  simple  reflux  of  the  blood  from  the  distended 
uterus  into  the  tubes  but  by  hemorrhage  from  the  mucous  membrane 
of  the  tubes  themselves  (Schroeder) ;  the  uterine  end  of  the  Fallopian 


FIG.  303. 

ATRESIA  VAGINAE,  SEEN  FROM  BEHIND.  Thickness  of  obstruction  (through  which  a  probe  is  passed) 
8-4 mm. ;  of  vaginal  wall  below  atresia  2-3  mm.,  abort  it  (at  x)  6mm.  Dilatation  of  the  body  of 
the  uterus  is  small  compared  with  the  common  cavity  formed  by  cervix  and  upper  portion  of 
vagina.  Left  Fallopian  tube  markedly  dilated,  with  no  distinct  flexion  on  it,  and  changed  at 
its  free  end  into  a  thin-icalled  blood  sac  which  had  burst.  Right  tube  undiluted.  (Breiiky) 

tube  is  sometimes  undilated  or  even  entirely  closed.  Blood  may  escape 
gradually  from  the  fimbriated  end  of  the  tube,  and  set  up  a  localised 
peritonitis  matting  down  the  tube  and  uterus ;  a  hsematocele  is  some- 
times thus  produced. 

2.  ATRESIA  VAGINALIS.  The  thickness  of  the  obstruction  varies  in 
different  cases,  according  to  the  extent  of  the  original  obliteration  and 
the  thinning  produced  by  the  pressure  from  above.  The  dilatation  of  the 

2K 


5H 


AFFECTIONS  OF    VAGINA. 


Seat  of 
Obstruc- 
tion. 


vagina  above  the  obstruction  is  remarkable ;  it  may  form  a  tumour 
filling  the  pelvis,  pressing  on  the  bladder  and  rectum,  and  raising  the 
uterus  above  the  brim  ;  the  walls  become  hypertrophied  as  is  well  seen 
in  the  preparation  represented  in  fig.  303,  taken  from  a  patient  who 
died  on  the  same  day  as  the  operation  for  atresia  was  performed. 

The  seat  of  the  obstruction  is  most  frequently  in  the  lower  third  of  the 
vagina.  This  condition  may  be  mistaken  for  imperforate  hymen ;  as 
the  wall  of  the  sac,  bulging  through  the  hymeneal  orifice,  becomes 
adherent  to  the  hymen  which  appears  as  a  mere  fringe  on  the  bulging 
membrane.  There  is  not,  however,  the  same  distension  of  the  vulvar 


FI;J.  304. 

CASE  or  DOUBLE  ATRESIA.  The  lower  affects  the  hymen  and  was  acquired;  above  this  was  a  cavity 
one  inch  long  which  contained  purulent  debris  :  the  upper  obstruction  was  one  inch  thick  and 
was  congenital;  above  it  is  the  dilated  uterus  and  cervix.  The  Fallopian  tubes  contain  blood- 
sacs  with  small.rents  in  their  walls  (Breiiky,  case  reported  by  Steiner). 

orifice  and  perineum  as  in  atresia  hymenalis.  Atresia  of  the  whole 
vagina  is  visually  associated  with  imperfect  development  of  the  uterus 
(Breislcy). 

Atresia  may  exist  at  more  than  one  point  in  the  vagina.  The  speci- 
men represented  in  fig.  304  illustrates  this.  It  has  this  further  interest 
that  the  lower  atresia — at  the  vaginal  orifice — was  acquired,  the  result 


ATRESIA    VAGINAE.  515 

of  a  fall  on  a  block  of  wood  when  the  patient  was  two  years  old ;  the 
upper  atresia  was  congenital  The  accumulation  of  menstrual  blood  in 
the  upper  sac  called  for  operative  interference  when  the  patient  was 
seventeen  years  of  age.  The  lower  sac  contained  purulent  matter.  On  the 
fifteenth  day  after  the  operation,  death  occurred  from  septic  peritonitis. 

The  character  of  the  retained  menstrual  blood  is  peculiar.     It  is  of  a  character 
brownish  chocolate-red  colour,  of  a  thick  treacle-like  consistence,  and of  retained 
contains  no  coagula.      Microscopically,  it  shows  shrivelled  red  blood- 
corpuscles,  flat  epithelial  cells,  mucous  corpuscles,  extravasated  blood- 
pigment,  and  granular  debris.     The  mucus  prevents  coagulation ;  part 
of  the  fluid  portion  is  probably  reabsorbed,  since  the  quantity  removed 
is  less  than  the  sum   of  what  we  should  expect  from  the  successive 
periods  passed. 1 

ETIOLOGY". 

1.  Atresia  may  be  congenital,  due  to  non-development  of  a  part  of  Congenital 
the  canal  or  its  subsequent  closure  during  foetal  life.  Atresia. 

Atresia  hymenalis  implies  that  the  hymeneal  folds  were  developed 
(at  the  nineteenth  week)  but  afterwards  became  blended  into  a  con- 
tinuous membrane. 

Atresia  of  the  vagina  behind  the  hymen  is,  according  to  Dohrn,  due  to 
the  fact  that  (at  the  eighteenth  week  of  foetal  life)  the  walls  of  the 
genital  canal  become  closely  approximated  behind  the  site  of  the 
hymen,  so  that  closure  of  the  vagina  is  especially  favoured  in  that  part. 

Atresia  of  the  middle  or  upper  third  implies  the  development  of  the 
ducts  and  their  coalescence  into  a  vagina,  with  a  subsequent  occlusion 
due  perhaps  to  inflammation  (Breisky). 

Complete  absence  of  the  vagina  or  its  representation  by  a  fibrous  cord 
is  due  to  the  non-development  of  the  ducts  of  Miiller ;  absence  of  the 
lower  third  is  occasioned  by  the  non-extension  of  the  ducts  downwards 
so  as  to  open  into  the  cloaca. 

2.  Atresia  is  also  acquired;  that  is,  it  arises  daring  life.     The  mostAcquired 
important  causes  which  produce  this  condition  are  the  following : — 

Sloughing  and  subsequent  cicatrisation  after  labour  ;  2 

Sloughing  from  impaired  vitality  in  typhus,  scarlet-fever,  small- 
pox, and  cholera ; 

Cicatrisation  after  injuries  received  in  childhood ; 

Superficial  inflammation  of  the  mucous  membrane,  leading  to 
adhesion  of  apposed  surfaces. 3 

1  Oliver  gives  Bedson's  chemical  analysis  of  the  retained  blood  in  a  recently  reported  case :  "It 
gave  the  spectrum  of  reduced  hajmatin,  and  contained  '6  p.c.  of  urea ;  100  c.c.  contained  total  so 
7-65  grms.,  organic  compounds  6'93  grms.,  mineral  compounds  -72  grms.     In  the  solids  were  f 
salts,  for  example,  chlorides,  sulphates  and  phosphates,  and  such  bases  as  iron,  calcium,  magnesium 
and  sodium :  Brit.  Mcd.  Jottrn.,  1888,  II.,  p.  1160. 

2  As  in  the  cases  recorded  by  Holdsworth  (Lan-:et,  1883,  I.,  p.  949) and  Cross  (Amer.  /ourn.  ObsM., 
1883,  p.  809,  and  1SS6,  p.  802).  ....    .        .  .  .    tt 

a  As  in  the  case  recorded  by  More  Madden  (Dublin  Med.  Journ.,  LXXV.,  p.  158),  m  which 
developed  in  a  multipara  after  a  miscarriage. 


516  AFFECTIONS   OF    VAGINA. 

The  commonest  form  of  congenital  atresia  is  due  to  imperforate 
hymen ;  of  acquired,  is  due  to  cicatrisation  of  the  upper  part  of  the 
vagina  and  cervix  after  labour. 

SYMPTOMS. 

As  congenital  atresia  is  productive  of  bad  results  only  in  so  far  as  it 
impedes  the  menstrual  flow,  symptoms  do  not  arise  till  puberty. 
Should  menstruation  not  take  place  at  puberty,  the  condition  may  not 
attract  attention  till  the  patient  enters  married  life. 1  Cases  are  however 
on  record  in  which  the  accumulation  of  mucus  has  called  for  operative 
interference  even  in  childhood. 

Symptoms  At  puberty  the  patient  experiences  menstrual  molimina  without  the 
Puberty  appearance  of  a  discharge.  As  the  vaginal  sac  distends,  pain  is  felt  in 
the  pelvis  at  first  only  at  the  periods  and  then  more  continuously. 
With  this  there  is  also  constitutional  disturbance.  The  periods  of 
suffering  become  more  protracted,  the  intervals  of  relief  shorter.  When 
the  dilated  vagina  presses  on  the  bladder  and  rectum,  it  causes  difficulty 
in  micturition  and  defsecation.  The  abdomen  swells  and  this,  with  the 
amenorrhcea,  causes  suspicion  of  pregnancy  which  is  sometimes  the 
occasion  for  seeking  advice.  If  the  case  is  left  to  itself  it  terminates 
fatally  through  rupture  of  the  uterus  or  cervix  (usually  the  latter)  or  of 
a  blood  sac  in  the  Fallopian  tube,  or  through  a  simple  or  septic  peri- 
tonitis independently  of  rupture.  In  some  cases,  the  obstructing  mem- 
brane has  given  way  by  rupturing  (in  acquired  atresia)  or  sloughing  (in 
the  congenital  form).  But  even  this  is  not  a  favourable  termination,  as 
the  risks  consequent  on  operative  interference  are  still  more  likely  to 
ensue  when  the  hymen  ruptures  of  itself. 

DIAGNOSIS. 

The  importance  of  physical  diagnosis  will  be  evident  from  the  follow- 
ing case.  "A.  B.,  set.  16,  unmarried,  has  for  twelve  months  suffered 
from  pain  in  the  pelvis  and  back,  with  occasional  acute  exacerbations 
accompanied  by  nausea  and  vomiting.  She  has  been  treated  for  inflam- 
mation ;  and  mercurial  ointment  had  been  applied  to  a  swelling  which 
had  appeared  in  the  left  groin,  on  the  supposition  that  it  was  an  enlarged 
gland."  Examination  per  rectum  showed  a  condition  similar  to  that 
seen  at  fig.  306 ;  the  swelling  in  the  left  groin  was  the  elevated  uterus. 

The  practitioner  will  often  ask  himself  whether  a  vaginal  examination 
is  necessary.  On  the  patient's  returning  several  times  and  there  being 
nothing  in  the  constitutional  state  (phthisis,  chlorosis)  to  explain  the 
amenorrhoea,  tell  the  friends  that  there  is  no  apparent  cause  for  the 

1  Zinnstag  records  a  curious  case  in  which  an  apparently  imperforate  hymen  was  not  observed 
until  labour  set  in  ;  there  must  have  been  a  perforation  (to  account  for  conception)  at  one  time,  but 
it  had  closed  subsequently :  Centratb.f.  Gyn.,  XII.,  S.  219.  Doleris  reports  a  similar  case  :  Archiv. 
de  Toe.  1886,  p.  135. 


AT  RE  SI  A    VAGINAE. 


517 


non-appearance  of  menstruation  except  on  the  supposition  of  a  mechani- 
cal obstruction  to  its  outflow.  If  there  be  pain  in  the  pelvis  and 
marked  constitutional  disturbance,  the  reasons  for  demanding  an 
immediate  examination  will  be  evident.  The  conditions  found  in  the 
various  forms  of  atresia  will  be  easily  understood  by  studying  figs.  305 
to  308.  The  external  genitals  are  first  examined ;  a  wide  urethral 
orifice  may  be  mistaken  at  first  glance  for  the  vagina,  as  in  atresia 
hymenalis  the  urethral  orifice  is  more  patulous  than  it  is  normally 
(Oldkam) ;  the  hymen  is  seen  biilging  forwards  at  the  ostium  vaginae. 
The  finger  is  passed  into  the  rectum  and  feels  that  the  anterior  Avail  is 
made  to  bulge  by  a  tense  elastic  sac.  On  bimanual  (recto-abdominal) 
examination,  this  sac  is  felt  to  be  equally  distended  and  to  fill  the 
pelvis ;  it  may  extend  into  the  abdomen  as  far  as  the  umbilicus.  The 
feeling  of  the  sac  is  quite  characteristic  and  is  like  that  of  a  tense 


FIG.  305. 

ATRESIA  HYMENALIS  (Sclroider). 


FIG.  306. 

ATRESIA  V AGIN*— lower  third  (Sckrotdtr). 


india-rubber  ball ;  on  its  upper  surface,  the  uterus  is  felt  as  a  small 
firmer  tumour. 

In  atresia  vaginae  the  condition  is  the  same,  except  that  the  hymen 
does  not  bulge  and  that  the  sac  does  not  extend  so  low  down. 

Atresia   of  the   cervix  (figs.  307,  308)  might  be  mistaken  for  earl 
pregnancy;   as  the  amenorrhcea  and  the  distended  uterus  are  present nancy> 
in  both  cases.     But  the  condition  of  the  cervix,  the  form  of  the  uterus, 
and  specially  the  characteristic  tense  feeling  of  the  tumour,  enable  us 
to  distinguish  it  from  a  pregnant  uterus.     Malignant  tumours  (sarco-From  Sa 
mata)  have  a  similar  elastic  consistence,  but  with  them  we  should  not 
have  amenorrhcea. 

It  is  not  in  all  cases  easy  to  say  whether  the  atresia  be  congemfe 


518 


AFFECTIONS  OF   VAGINA. 


acquired.  The  existence  of  other  malformations  would  favour  the 
former  view,  of  cicatrices  beside  the  obstruction  the  latter.  There 
will  also  be  a  greater  thickness  of  tissue  felt  between  the  urethra  and 
rectum  in  the  acquired  form,  corresponding  to  the  obliterated  vaginal 
canal. 

Efs™mtati?n  In  atresia  vaginae  it  is  important  to  estimate  the  distance  to  which 
of  Atresia.  atresia  extends,  so  that  we  may  know  how  much  tissue  we  must  cut 
through  to  reach  the  sac  or  the  cervix  uteri.  This  is  best  done  by 
passing  the  index  finger  into  the  rectum  till  the  tip  is  on  the  place 
where  the  bulging  of  the  sac  begins  or  where  the  projection  of  the 
cervix  is  felt ;  the  thumb  is  at  the  same  time  passed  into  the  ostium 
vaginae  till  it  reaches  the  obstructing  membrane ;  the  thickness  of  the 
latter  can  thus  be  estimated. 


FIG.  307. 

ATRESIA  OF  CERVIX  AT  Os  EXTEKNUM 
(Schroeder). 


FIG.  308. 

ATRESIA  OF  THE  CERVIX  AT  Os  INTERXUM 
{Schroeder). 


PROGNOSIS. 

If  menstrual  blood  be  accumulating,  the  prognosis  is  always  grave. 
In  atresia  of  the  hymen  the  prospect  of  cure  by  operative  treatment  is 
more  hopeful  than  in  congenital  atresia  of  the  vagina.  In  acquired 
atresia  of  the  vagina,  if  the  obstruction  be  removable,  the  prognosis  is 
favourable.  The  unfavourable  cases  are  those  in  which  the  vagina  is 
partially  or  not  at  all  developed ;  the  prognosis  as  to  curability  by 
operation  depends  on  the  thickness  of  the  tissue  between  the  urethra 
and  the  rectum,  which  determines  the  possibility  of  opening  up  a 
vagina. 

When  menstrual  blood  has  accumulated,  while  explaining  to  the 
patient's  friends  the  necessity  of  immediate  operative  treatment,  we 


AT  RE  SI  A    VAGINAE.  519 

should  inform  them  also  of  the  dangers  attendant  on  the  operation — 
the  immediate  danger  of  rupture  of  a  blood  sac  in  the  Fallopian  tube, 
the  more  remote  one  of  simple  or  septic  peritonitis. 

The  seriousness  of  the  complication  of  hsematosalpinx  is  seen  in 
Fuld's  statistics  :l  of  sixty-five  which  he  has  collected,  more  than  two- 
thirds  (forty-eight)  died ;  while  seventeen  were  saved  by  operation. 

TREATMENT. 

The  treatment  consists  in  the  formation  of  a  channel  to  allow  the 
menstrual  blood  to  escape ;  in  the  case  of  imperforate  hymen  this  is 
easily  done  by  incising  the  membrane,  but  in  atresia  vaginae  we  have  to 
construct  a  new  vaginal  canal.  Two  dangers  associated  with  this  Dangers  of 
operation  must  be  kept  in  view.  First,  too  rapid  collapse  of  the  sac 
may  lead  to  rupture  of  the  Fallopian  tubes  or  of  vascular  adhesions 
round  the  uterus.  This  rupture  may  be  brought  about  in  the  following 
way,  as  has  been  shown  by  post-mortem  examination.  The  Fallopian 
tube  has  been  previously  bound  down  to  the  side  wall  of  the  pelvis  by 
adhesions  ;  when  the  sac  is  opened  into,  the  uterus  necessarily  follows 
its  retreating  wall  and,  if  this  retreat  takes  place  rapidly,  the  tube  is 
exposed  suddenly  to  a  strain  which  ruptures  it ;  death  results  from 
haemorrhage  or  peritonitis.  To  prevent  this  accident,  the  operator 
should  allow  the  contents  of  the  sac  to  escape  slowly  and  should  on  no 
account  apply  pressure  from  above  to  hasten  the  process.  Second,  the 
operation  is  frequently  followed  by  septicaemia.  To  prevent  this,  anti- 
septics should  be  used.  Listerism  cannot  be  carried  out  here  ;  but  by 
washing  out  the  sac  carefully  with  carbolised  water,  preventing  the 
entrance  of  air,  and  allowing  free  drainage  when  fluid  collects,  we 
greatly  diminish  this  risk.  The  danger  of  rupture  of  hsematosalpinx 
has  only  recently  been  recognised.  Puncturing  of  the  dilated  tube  is 
now  abandoned  for  abdominal  section  ;  and  salpingotomy  (Tait's  opera- 
tion) should  be  performed  in  addition  to  the  evacuation  of  the  distended 
vagina  when  a  dilated  tube  is  present.2 

Another  danger,  which  follows  some  time  after  the  operation,  is  the 
contraction  of  the  new  canal  which,  unless  specially  guarded  against, 
may  lead  to  its  obliteration.  Emmet  expresses  this  well  when  he  says 
"  the  surface  of  the  canal  is  essentially  a  cicatricial  one,  and  will  con- 
sequently contract  to  a  greater  or  less  extent."  To  diminish  the  liability 
to  contraction,  he  recommends  that  the  tissues  be  torn  with  the  finger 
nail  or  broken  up  with  the  scissors  rather  than  divided  with  the  knife  ; 

*  Op.  cit.  These  cases  were  collected  from  all  sources,  and  before  the  operation  for  hwmatosalpinx 
was  a  recognised  one. 


palpation — 
called  for  in  both  cases. 


520  AFFECTIONS   OF   VAGINA. 

the  raw  surface  is  made  to  heal  upon  a  glass  plug.1  Crede  ~  prevented 
cicatrisation  by  taking  a  flap  from  the  labium  majus  and  turning  it  into 
the  vagina  so  that  it  could  be  stitched  to  the  cervix  and  to  the  raw 
surface  produced  by  dividing  the  old  cicatricial  tissue  in  the  vagina. 

We  shall  describe  shortly  the  operations  for  (1)  imperforate  hymen, 
(2)  atresia  of  the  vagina,  (3)  atresia  of  the  cervix. 

Operation  1.  Imperforate  Hymen.  This  operation,  though  apparently  simple, 
f orate  should  never  be  performed  in  the  consulting  room  but  always  at  the 
Hymen,  patient's  house  or  in  hospital.  The  time  chosen  should  be  between  two 
menstrual  periods  which  are  indicated  by  menstrual  molimina.  The 
hymen  is  punctured  with  a  small  trocar  which  has  been  rendered 
thoroughly  clean  and  aseptic  beforehand.  The  fluid  is  allowed  to  escape 
slowly.  After  it  has  ceased  to  flow,  the  opening  in  the  hymen  is 
enlarged  with  a  knife.  This  incision  is  made  in  the  form  of  a  cross,  or 
the  membrane  is  pinched  up  with  forceps  and  an  elliptical  portion  cut 
out.  A.  R.  Simpson  recommends  that  the  opening  in  the  hymen  be 
made  with  the  cautery,  which  prevents  septic  absorption  by  the  wound. 
We  can  dispense  with  the  trocar  if  we  take  care  to  make  at  first  only  a 
small  opening,  which  can  afterwards  be  enlarged.  A  stream  of  warm 
antiseptic  water  is  now  made  to  flow  gently  into  the  cavity  ;  the  open- 
ing should  be  large  enough  to  permit  the  fluid  to  flow  outwards  at  the 
same  time,  so  that  the  sac  may  be  washed  out  without  being  subjected 
to  any  pressure.  A  plug  of  lint  soaked  in  antiseptic  oil  is  placed  in  the 
hymeneal  orifice,  and  a  larger  pad  over  the  vulva.  The  patient  keeps 
her  bed  for  ten  days  after  the  operation.  If  there  be  a  rise  of  tempera- 
ture or  other  indication  of  septic  inflammation,  the  vagina  should  be 
again  washed  out. 

Operation  2.  Atresia  of  the,  Vagina.  The  patient  is  placed  in  the  lithotomy  pos- 
Vaginse.  ture,  and  the  labia  are  retracted  by  the  fingers  of  the  assistants  who  hold 
the  thighs.  The  sound  is  passed  into  the  previously  emptied  bladder  ; 
it  is  then  held  by  an  assistant  in  such  a  way  that  the  urethra  and  bladder 
are  drawn  well  upwards  towards  the  pubes.  The  index  finger  (with,  if 
necessary,  the  second)  of  the  left  hand  is  introduced  into  the  rectum  ; 
and  the  thickness  of  tissue  between  the  finger  and  the  sound,  as  well  as 
the  position  of  the  distended  sac  above,  carefully  ascertained  :  the  finger 
is  kept  in  the  rectum  during  the  operation,  both  to  hook  that  structure 
backwards  so  as  to  prevent  its  being  cut  into  and  to  guide  in  tearing  up 
the  septum.  Should  the  operator  wish  to  have  both  his  hands  free  to 
use  instruments,  an  assistant  can  pass  the  finger  into  the  rectum.  The 
operator  now  makes  with  a  knife  a  transverse  incision  over  the  hymen, 
or  through  the  skin  between  the  anus  and  the  urethra.  When  the  sac 

1  In  the  Americ.  Journ.  Obst.  (1887,  p.  1180)  he  refers  to  his  attending  in  her  second  confinement  a 
patient  on  whom  he  had  operated  ten  years  previously  to  make  an  artificial  vagina  when  she  was 
fifteen  years  old. 

1  Archivj:  Gyn.,  Bd.  XXII.,  S.  229. 


AT  BE  SI  A    VAGINAE. 


521 


is  reached,  it  is  punctured  and  washed  out  with  the  same  precautions  as 
in  the  operation  for  imperforate  hymen  ;  it  is  then  carefully  and  gently 
packed  with  strips  of  lint  soaked  in  antiseptic  oil.  These  are  taken  out 
en  the  following  day,  but  a  tightly  fitting  plug  is  left  in  the  newly 
formed  portion  of  the  vagina  to  prevent  its  contraction  ;  after  three  or 
four  days,  a  perforated  glass  plug  (fig.  309)  is  passed  in  to  keep  the  new 
canal  dilated.  The  plugs  are  made  of  various  thicknesses,  and  have  a 
rim  at  the  external  end  to  prevent  their  being  pushed  in  too  far.  The 
plug  must  not  be  so  long  as  to  press  on  the  roof  of  the  vagina,  and 
should  be  of  such  a  thickness  that,  while  it  can  be  easily  slipped  out 
and  in  by  the  wearer,  it  stretches  the  new  canal ;  it  is  kept  in  position 
by  tapes  which  are  fastened  to  the  rim  and,  before  and  behind,  to  an 
abdominal  band.  A  pessary  can  be  employed  subsequently ;  some 
instrument  may  have  to  be  worn  constantly  for  a  year  or  more  and 
where  there  is  continued  tendency  to  contraction,  for  a  short  period 
daily  during  many  years. 

In  a  case  operated  on  by  Page,  there  was  an  accumulation  of  fluid  in 


PK 


FIG.  309. 

•RFORATFD  GLASS  PLUG  TO  BE  USED  AFTER  OPERATION  FOR  AlRESIA  VACIN/E. 
figure  shows  the  external  end  of  the  tube  with  the  tapes  attached. 


The  left  hand 


the  vagina,  and  a  second  in  the  uterus  itself  which  did  not  discharge 
till  the  cervix  was  incised.1 

This  operation  has  been  performed  even  when  there  has  been  no 
accumulation  of  menstrual  blood.  The  indications  for  operating  are  thus 
given  by  Thomas  :  "  It  should  be  resorted  to  (a)  if  menstrual  blood  be 
imprisoned ;  (b)  if  a  uterus  can  be  distinctly  discovered  and  the  patient 
be  suffering  from  absence  of  menstruation ;  (c)  if  the  necessity  for  sexual 
intercourse  be  imperative."  Cases  have  been  recorded  in  which  the 
formation  of  a  vaginal  canal  has  led  to  the  establishment  of  menstrua- 
tion when  it  was  formerly  absent,  to  the  development  of  the  uterus  and 
ovaries  where  these  were  rudimentary  (?),  or  to  an  improvement  in  tl 
general  health  of  the  patient  although  there  was  no  indication  of  furth 
development  in  the  rudimentary  uterus  and  ovaries. 

More  difficulty  is  experienced  in  operating  where  there  is  no  accumu- 
lation of  menstrual  blood  and  the  vagina  is  entirely  absent  or  represents 

i  lancet  1884,  I.,  p.  706. 


522  AFFECTIONS   OF   VAGINA. 

by  a  fibrous  cord.  In  such  a  case,  there  is  not  the  same  necessity  for 
surgical  interference  unless  it  be  to  satisfy  the  claims  of  married  life. 
If  the  uterus  and  ovaries  be  well  developed  and  the  patient  be  anxious 
to  have  her  condition  remedied,  the  operation  is  justifiable.  Here  we 
have  not  the  distended  sac  as  a  guide  to  the  point  on  which  we  are  to 
cut  down.  The  cervix,  of  which  the  position  should  be  ascertained  by  a 
combined  recto-abdominal  examination,  should  be  fixed  as  far  as  possible 
by  an  assistant's  making  firm  pressure  from  above  upon  the  uterus ; 
there  is  no  danger  in  such  pressure  if  there  be  no  accumulation  of 
menstrual  blood.  The  mode  of  procedure  is  the  same  as  that  just 
described. 

Operation  3.  Atresia  of  the  cervix.  Usually  the  obstruction  is  so  slight  that  the 
Cervicis.  forcible  passage  of  the  sound  overcomes  it.  Should  the  obstruction 
resist  all  efforts  to  pass  the  sound  we  require  to  use  the  knife  to  open 
the  canal.  If  the  uterus  be  much  distended  with  menstrual  blood,  it  is 
safer  to  empty  it  first  with  the  aspirator-needle  passed  through  one  of 
the  fomices ;  the  emptying  should  be  effected  slowly  and,  if  the  disten- 


FIG.  310. 

BREISKY'S  FORCEPS,  TUBE  AND  NOZZLE,  FOR  OPERATING  IN  ATRESIA  OF  THE  CERVIX  (Breisky). 

sion  be  considerable,  at  more  than  one  sitting ;  rapid  emptying  is  apt 
to  set  up  uterine  contractions  which  may  produce  rupture  of  a  dilated 
Fallopian  tube.  To  open  up  the  cervical  canal,  the  following  method  is 
adopted  by  Thomas.  The  cervix  is  steadied  with  a  tenaculum.  A  long 
exploring  needle  is  passed  along  the  line  of  the  cervical  canal  into  the 
uterine  cavity,  the  sense  of  resistance  overcome  and  the  escape  of  a  drop 
of  blood  indicating  that  the  needle  has  reached  it.  A  delicate  tenotome 
is  placed  in  the  gutter  of  the  needle  and  pushed  upwards  for  the  required 
distance.  This  process  is  repeated  so  as  to  divide  the  cervix  on  four 
sides  in  a  radiate  manner.  The  cavity  of  the  uterus  is  washed  out  with 
a  syringe,  and  a  glass  tube  passed  into  the  cervical  canal  to  keep  it  open. 
Breisky  has  devised  the  instruments  represented  in  fig.  310,  to  facili- 
tate the  washing  out  of  the  uterine  sac  in  cases  of  extensive  atresia  of  the 
vaginal  canal  and  cervix  with  haBmatometra.  The  septum  which 
separates  the  urethra  and  bladder  from  the  rectum  is  split  up  so  as  to 
form  a  new  vagina,  and  the  cervix  is  thus  exposed.  To  form  the  new 


AT  RES  I A    VAGINAE. 


523 


cervical  canal,  Breisky  employs  a  knife-edged  trocar  running  in  a  canula. 
The  canula  is  pressed  firmly  against  the  cervix,  and  the  knife  is  run  out 
piercing  through  the  cervix  into  the  dilated  uterus  above ;  the  canula  is 
then  run  on  the  knife  into  the  cavity,  and  the  knife  withdrawn.  The 
contents  of  the  sac  escape  through  the  canula.  The  forceps  represented 
at  fig.  310  are  now  passed  in  with  one  blade  on  each  side  of  the  canula. 
They  are  forcibly  opened  so  as  to  distend  the  new  canal  still  further, 
and  serve  to  keep  it  patulous  while  the  canula  is  withdrawn  and 
the  tube  represented  at  fig.  310  inserted  in  its  place.  This  tube  has 
two  channels ;  into  one  of  these  a  nozzle  (fig.  310)  fits  and  is  employed 
to  pass  the  stream  of  water  into  the  sac,  while  the  outflow  takes  place 
by  the  other. 

Atresia  of  one  half  of  a  Septate  Uterus  and  Vagina. 
This  form  of  atresia  has  certain  characteristics  which  distinguish  it 
from  the  other  forms  described  above. 


FIG.  311. 

SEPT  WE  UTERUS  ;  the  right  half  is  pervious,  the  left  half  has  been  distended  with  retained 
menstrual  blood  (Schroeder). 

The   chief  peculiarity   is   that   it  presents  the  phenomena  of  free 
menstruation  +  those  of  retained  menstruation. 

The  pathological  condition  is  apparent  from  fig.  311.     Spontaneous 
rupture  of  the  septum  with  escape  of  the  retained  fluid  (in  this  case 
through  the  patulous  uterus  or  vagina)  occurs  more  frequently  in  t 
than  in  other  forms  of  atresia;  rupture  of  the  Fallopian  tube,  with  its 
fatal  consequences,  is  also  a  more  frequent  occurrence  (Punch). 
spontaneous  rupture  of  the  septum  does  not  usually  occur  at  its  lowes 
point ;  hence  there  is  liability  to  accumulation  of  purulent  matter 
pouch  below  the  point  of  perforation,  which  is  a  source  of  septicaemia 

The  symptoms  are  the  same  as  in  the  other  forms  of  atresia,  but  1 


524  AFFECTIONS  OF   VAGINA. 

are  masked  by  the  presence  of  a  menstrual  flow.  This  visible  menstrua- 
tion is  often  irregular,  and  profuse  leucorrhoca  (from  the  patuloxis  cavity) 
is  frequently  present. 

Physical  examination  shows  a  fluctuating  tumour  lying  beside  the 
uterus  and  alongside  of  the  patulous  vaginal  canal.  Sometimes  it  winds 
in  a  spiral  manner  round  the  latter. 

The  diagnosis  is  not  difficult  if  the  blind  sac  extend  to  the  ostium 
vaginas  and  be  felt  running  alongside  of  the  vaginal  canal  or  winding 
round  it.  If,  however,  it  be  limited  to  the  side  of  the  uterus  or  only 
extend  partially  on  to  the  vagina,  it  may  easily  be  mistaken  for  other 
para-uterine  tumours — most  frequently  for  hsematocele.  To  clear  up 
the  diagnosis  and  also  as  a  step  towards  treatment,  we  puncture  the  sac 
with  the  aspiratory -needle.1  The  character  of  the  discharged  blood 
will  indicate  the  diagnosis. 

The  treatment  consists  in  slowly  but  thoroughly  evacuating  the  sac, 
washing  out  and  establishing  a  permanent  opening  from  it. 

A  septate  vagina  is  sometimes  found  with  a  septate  uterus  (v.  fig.  149), 
both  halves  being  pervious  so  that  there  are  no  symptoms. 2  In  rare 
cases,  the  one  vagina  is  imperforate.  Kleimvachter3  records  an  interest- 
ing case  of  a  bulging  tumour  of  the  anterior  vaginal  wall  resembling  in 
position  a  cystocele  ;  it  ruptured  and  pus  escaped.  On  laying  open  the 
fistulous  tract,  its  walls  had  the  naked  eye  and  microscopic  characters 
of  vaginal  mucous  membrane  in  a  state  of  inflammation.  Traces  of  a 
septate  condition  may  persist  as  bands. 

1  Kiderlen  mentions  a  case  from  Martin's  Clinic  in  which  about  21  pints  of  fluid  were  evacuated 
from  the  dilated  right  half  of  the  vagina  and  uterus  :  Zeits.f.  Geb.  v.  Gyn.,  B.  XV.,  S.  1. 

2  Cullingworth  has  recorded  recently  two  cases  of  a  transverse  septum  in  the  lower  part  of  the 
vagina :  Lancet,  1889,  I.,  p.  726. 

a  Zeits.f.  Geb.  u.  Gyn.,  B.  XL,  S.  254. 


CHAPTER  XLVI. 

VAGINITIS:  VAGINISMUS:  TUMOURS. 

LITERATURE  OF  VAGISITIS. 

Barnes— Diseases  of  AVomen,  p.  865  :  London,  1878.  Hennig—T>er  Katarrh  der  weib- 
lichen  Geschlechtsorgane.  Hildcbrandt  —  Monat.  f.  Geb.,  Btl.  XXXII.,  S.  128. 
Macdonald,  Angus— Edin.  Med.  Journ.,  June  1873.  Miller,  A.  G.—  Four  and  a 
Half  Years'  Experience  in  the  Lock  Hospital,  Edinburgh  :  Edin.  Med.  Journ.,  1883. 
Nceggerath— Latent  Gonorrhoea  in  the  Female  Sex  :  Am.  Gyn.  Trans.,  Vol.  I.,  p.  268. 
Buge — Ueber  die  Anatomic  der  Scheidenentziindung :  Zeitschrift,  f.  Geb.  u.  Gyn., 
Bd.  IV.,  S.  133.  Schroeder — Die  Krankheiten  der  weiblichen  Geschlechtsorgane, 
S.  460  :  Leipzig,  1879.  Thomas  —  Diseases  of  Women,  p.  211 :  London,  1882. 
Winckel — Colpohyperplasia  cystica,  etc.  :  Arch.  f.  Gyn.,  Bd.  II.,  S.  400.  See  also 
Index  of  Recent  Gynecological  Literature  hi  Appendix. 

VAGINITIS. 

SYXOXYMS. — Colpitis  (Gr.  K6X7ros,  a  fold) :  Elythritis  (Gr.  tKvrpov,  a 
sheath). 

NATURE    AND    VARIETIES. 

Vaginitis  is  an  inflammation  of  the  mucous  membrane  of  the  vagina. 
The  structure  of  this  mucous  membrane  has  been  already  described 
(v.  p.  27).  From  its  consisting  of  connective-tissue  papillae  covered  with 
several  layers  of  squamous  epithelium,  it  resembles  the  structure  of  the 
skin  rather  than  that  of  a  mucous  membrane ;  exceedingly  few  mucous 
glands  are  present.  Consequently,  the  inflammatory  changes  are  more 
allied  to  those  of  the  skin  than  to  those  of  a  mucous  membrane 
(Schroeder). 

According  to  etiology,  vaginitis  is  either  simple  or  gonorrJioeal.  Apart 
from  the  history,  we  cannot  for  certain  distinguish  between  these  (v. 
Etiology). 

The  clinical  distinction  between  acute  and  chronic  vaginitis  is  merely 
a  question  of  degree. 

Diphtheritic  vaginitis  will  be  referred  to  by  itself. 

Senile  vaginitis  is  one  of  the  physiological  retrogressive  processes 
occurring  after  the  menopause. 

PATHOLOGY. 

Yaginitis  occurs  most  frequently  in  the  form  of  slight  elevations  ° 
the  mucous  membrane,  which  produce  a  granular  surface.  These  granu- 
lations, according  to  Huge,  consist  of  groups  of  papillae  infiltrated  with 


526 


AFFECTIONS  OF   VAGINA. 


small  cells ;  these  swell  up  and  push  before  them  the  stratified  squamous 
epithelium,  the  superficial  layers  of  which  are  shed  (fig.  312).     When 


FIG.  312. 

GRANULAR  VAGINITIS — acute  form  (Schrocder). 


the  condition  has  existed  some  time,  the  surface  becomes  more  equal 
through  the  thinning  of  the  epithelial  covering  (fig.  313). 


FIG.  313. 

GRANULAR  VAOINITIS— chronic  form  (Schroecler). 


Emphyse-       Associated  with  vaginitis  in  pregnancy,  there  is  sometimes  an  emphy- 

matpus       sematous  condition  of  the  vaginal  mucous  membrane.      Winckel  has 
Vaginitis. 


FIG.  314. 

COLPITIS  EMPHYSEMATOSA  (Sclirotdir). 


described  cysts  containing  gas  and  fluid ;  according  to  Huge,  the  air  is 
present  in  spaces  among  the  cellular  tissue  (fig.  314),  while  Zweifel 


VAGINITIS.  527 

thinks  they  arise  from  vaginal  glands  the  ducts  of  which  have  been 
closed  by  inflammation.  This  form  of  inflammation  cannot  be  separated 
from  vaginal  cysts,  to  be  noticed  on  p.  533. 

In   gonorrhoeal  vaginitis,    a   gonococcus  is  present  which  was  first  Conor- 
described  by  Neisser;  the  individual  is  like  a  coffee-bean  in  shape,  and  Vagiuitis. 
they   are   aggregated  in  round  clusters.      Burnm1   finds  its  presence 
to   be    diagnostic,   and   notes   this  interesting   fact,   that  the   seat  of 
its   propagation  is  the  urethral   and   cervical   mucous  membrane;    it 
cannot  burrow  through  the  many-layered  squamous  epithelium  of  the 
vagina. 

The  cicatricial  contraction  of  the  vagina  observed  after  the  meno- 
pause is  due  to  a  senile  vaginitis.  The  epithelium  is  shed  in  patches, 
and  the  raw  surfaces  thus  produced  adhere  together  (Hildebrandt). 
This  process  is  similar  to  that  which  produces  occlusion  of  the  cervical 
canal  after  the  menopause. 

Diphtheritic  vaginitis  occurs  either  as  localised  patches  or  as  anDiphther- 
affection  of  the  whole  vagina.    In  the  latter  case,  the  mucous  membrane  vaginitis. 
may  be  so  swollen  that  the  finger  scarcely  reaches  the  cervix,  which  also 
is  found  to  be  thickened  and  covered  with  the  diphtheritic  membrane. 

ETIOLOGY. 

The  following  are  the  most  important  causes : — 

Gonorrhceal  infection ; 

Irritating  discharges  from  the  uterus  ; 

Injurious  vaginal  injections,  badly  fitting  pessaries,  or  other  causes 

which  injure  the  vaginal  mucous  membrane ; 
Exanthemata. 

Gonorrhoeal  infection  produces  the  most  intractable  form  of  vaginitis,  Gonor- 
which   may  extend  over  months  or  years.      The  poison  may  spread 
alon"   the    mucous    membrane   of  the    uterus    and    Fallopian  tubes 
causing  endometritis  (p.    321),  pyosalpinx  (p.   197),  and  pelvic  per 

tonitis  (p.  158). 

Irritating  discharges  from  the  uterus,  as  in  endometritis,  produce  aEndome- 
secondary  vaginitis  which  can  only  be  treated  by  curing  the  utenne 
affection.      In   carcinoma  and  vesico-vaginal   fistula,  vaginitis  ans< 

secondarily. 

Among  the  causes  which  irritate  or  injure  the  v^nal  mucous  inwbr aw,  K 
we  mention  injections  of  too  hot  or  too  cold  water  and  of  substances 
produce  abortion,  badly-fitting  pessaries,  tampons  or  pieces  of  spoi 
which  have  been  allowed  to  lie  some  days  in  the  vagina,    Vaginitis  may 
also  develop  on  a  patient's  entering  married  life,  simply  from  awkward 
ness  in  sexual  intercourse;   on  being  consulted  about  such  cases,  we 

i  Beitrag  2ur  Kenntnis*  der  Gonorrhea  der  weiblichen  Genitalien :  Ar**.f.  **,  *  * 


528 


AFFECTIONS   OF    VAGINA. 


Exanthe- 
mata as 
a  cause. 


must  remember  that  a  simple  vayinitis  may  produce  most  of  the  symptoms 
of  one  due  to  gonorrhoea. 

Diphtheritic  inflammation  occurs  \isually  in  the  puerperal  condition 
and  that  through  bad  hygiene.  It  has  been  observed  in  typhus,  small- 
pox, and  cholera,  and  also  in  some  cases  of  gonorrhoea.  Localised  diph- 
theritic patches  are  seen  in  fistulae,  in  carcinoma,  and  round  badly- 
fitting  pessaries. 


SYMPTOMS. 


These  are  the  following  : — 


A  burning  heat  in  the  vagina ; 
Pain  in  the  floor  of  the  pelvis  ; 
Frequent  desire  for  micturition,  with  a  scalding  sensation  while 

water  is  passing ; 
Free  muco-purulent  leucorrhoea. 

These  symptoms  are  present  both  in  simple  vaginitis  and  that  due  to 


FIG.  315. 

HENDERSON'S  VAGINAL  SPATUL^E  (A.  G.  Miller). 

gonorrhoeal  discharge.  In  the  latter  case,  the  urinary  symptoms  are 
more  pronounced  ;  there  is  a  distinct  period  from-  which  all  the  symptoms 
commenced,  their  duration  is  longer,  and  they  resist  treatment;  they 
are  often  complicated  with  those  of  enlarged  inguinal  glands,  endome- 
tritis,  cystitis,  or  pelvic  peritonitis. 

DIAGNOSIS. 

On  vaginal  examination,  the  finger  recognises  the  discharge  which 
escapes  on  separating  the  labia,  and,  in  many  cases,  the  rough  condition 
of  the  mucous  membrane. 

The  speculum  shows  that  the  mucous  membrane  is  inflamed  and 
covered  with  muco-purulent  discharge ;  the  redness  is  usually  in  the 
form  of  patches  but  may  be  diffuse. 

The  appearance  of  the  cervix  must  be  noted  to  ascertain  that  the 
leucorrhceal  discharge  does  not  come  from  it ;  the  differentiation  of  dis- 
charge from  the  uterus  and  that  from  the  vagina,  is  made  as  described 
on  page  309. 


VAGINITIS.  529 

Fig.  315  shows  two  spatulse  used  by  Henderson  of  Shanghai  in 
examining  gonorrhoeal  and  specific  cases.  They  are  exceedingly"  useful 
in  separating  the  labia ;  one  blade  can  be  employed  -as  a  Sims  speculum, 
and  pressure  can  be  made  along  the  anterior  vaginal  wall  over  the  course 
of  the  urethra  to  ascertain  if  there  is  any  urethritis. 

The  differential  diagnosis  between  simple  and  gonorrhoeal  vaginitis  is 
often  very  difficult.  The  history  of  a  distinct  source  of  infection  is  the 
only  certain  guide,  and  the  ascertaining  of  this  is  a  very  delicate  ques- 
tion. Apart  from  this,  the  following  conditions  point  to  a  gonorrhceal 
origin :  sudden  development  of  vaginitis  with  urinary  symptoms,  in  a 
patient  who  has  had  previously  no  marked  leucorrhoeal  discharge ; 
absence  of  any  other  cause  to  explain  these ;  protracted  duration  of 
•symptoms  and  resistance  to  treatment.  However  convinced  the  practi- 
tioner may  be  in  his  own  mind  that  the  vaginitis  is  of  a  specific 
nature,  the  social  unhappiness  caused  by  his  expressing  a  decided 
opinion  should  deter  him  from  giving  it  in  cases  where  a  cause  is  not 
admitted. 

Pelvic  abscesses  discharging  through  the  roof  of  the  vagina  have  been 
mistaken  for  vaginitis  (Thomas).  Such  a  mistake  will  not  arise  when 
the  Bimanual  and  other  methods  of  examination  are  employed.  We 
must  not  be  satisfied  with  finding  vaginitis ;  the  whole  routine  examina- 
tion of  the  pelvic  organs  must  be  made  after  the  pressing  symptoms 
have  been  relieved. 

TREATMENT. 

Iii  acute  cases,  rest  in  bed  is  necessary.  Hot  water  injections  are 
given  three  or  four  times  daily :  the  douche  is  much  more  convenient 
than  the  syringe ;  it  leaves  the  hands  free,  requires  less  exposure  of  the 
patient,  and  keeps  up  a  steady  stream  (v.  p.  138).  The  stream  should 
run  for  a  quarter  of  an  hour.  A  piece  of  gutta-percha  tubing,  weighted 
at  one  end  and  with  a  clip  at  the  other,  makes  a  handy  douche ;  the 
weighted  end  is  placed  in  a  ewer  of  water  above  the  level  of  the  bed,  the 
tube  is  coiled  up  in  the  water  so  as  to  be  filled,  the  clamp  is  put  on  at 
the  other  end  and  the  tube  withdrawn ;  the  syphon-action  is  started 
by  the  column  of  water  in  the  tube  and  continues  till  the  ewer  is 
empty.  The  bowels  are  freely  moved,  and  then  a  morphina  sup- 
pository is  given.  Complete  rest  from  sexual  activity  is  absolutely 
necessary. 

In  chronic  cases  or  after  the  acute  stage  has  passed  off,  astringents 
are  added  to  the  injections.  The  vaginal  walls  having  been  first 
thoroughly  dried,  a  solution  of  nitrate  of  silver  (3j  to  §j  of  water)  is 
applied  and  a  tampon  of  antiseptic  cotton  soaked  in  glycerine  and 
bismuth  introduced  to  keep  the  walls  apart.  Chloride  of  zinc  (2  grs.  to 
is  recommended  by  Fritsch. 

2L 


530 


AFFECTIONS  OF   VAGINA. 


Medicated       Applications  to  the  vagina  are  usually  made  by  means  of  medicated 
pessaries.     The  following  are  those  most  frequently  used1  : — 


Atropine 
Belladonna     . 

Sedative 
do. 

1-20  grain. 
2         do.  Alo.  Ext, 

Morphina 
Bismuth  Oxide 
Borax     . 

do.                                   i 
Cicatrising  &  Emollient  15 
do.                  do.       15 

do. 
do. 
do. 

Zinc  Oxide 

do. 

do.       15 

do. 

Tannin  . 
Alum 

Astringent 
do. 

10 
15 

do, 
do. 

Acetate  of  Lead  and 

Opium 
Gallic  Acid 

do. 
do. 

5 
10 

do,  2  grs.  Opium 
do. 

Persulphate  of  Iron 
Sulphate     of     Zinc 
(dried) 
Iodide  of  Lead 

Haemostatic 

Caustic 
Alterative  & 

5 

10 

Resolvent   5 

do, 

do. 
do. 

Mercurial 
Carbolic  Acid. 

do. 
Deodorant 

do.       30 
5 

do,  (  Ung.  Hydrarg. 
do. 

Tampons.        Lawton's  absorbent  cotton  2  is  the  best  material  for  vaginal  tampons 
which  are  to  be  soaked  in  glycerine  or  other  medicaments. 


Nature. 


VAG-INISMUS. 

LITERATURE.  Duncan,  Matthews — Diseases  of  Women,  p.  142 :  Lond.  1883,  Hcnrich- 
sen — Strictur  des  Scheidengewolbes,  bewirkt  durch  Krampf  des  Musculus  levator  ani ; 
Archiv  f.  Gyn.,  Bd.  XXIII.,  S.  59.  Hildebrandt — Ueber  Krampf  des  Levator  ani 
beim  Coitus;  Archiv  f.  Gyn.,  Bd.  III.,  S.  221.  Scanzoni — Lehrbuch  der  Krank- 
heiten  der  weiblichen  Geschlechtsorgane,  S.  704  :  "Wien,  1875.  Simpson,  Sir  J.  Y. 
— Edin.  Med.  Journ.,  Dec.  1861.  And  Diseases  of  Women,  p.  284 :  Edin.,  1872, 
Sims — Cases  of  Vaginismus  :  Americ.  Med.  Times,  1862,  Nos.  22  to  25.  Thomas — 
Diseases  of  Women,  p.  203 :  Lond.  1882.  Tilt— The  Lancet,  Aug.  1874. 

By  vaginismus,  we  understand  a  painful  reflex  contraction  of  the 
muscular  fibres  surrounding  the  vaginal  orifice — just  as  laryngismus  is 
applied  to  the  same  condition  in  the  larynx.  Marion  Sims  first  drew 
attention  to  this  condition. 


ETIOLOGY. 

It  is  found  in  some  patients  of  a  nervous  and  sensitive  temperament 
without  there  being  any  local  source  of  irritation,  but  this  is  excep^ 
tional. 

1  As  made  up  and  supplied  by  Messrs  Duncan,  Flockhart  &  Co. 
2  Sold  in  packets  (2  oz— J  lb.). 


VAGINISMUS.  531 

Usually  one  of  the  following  conditions  is  present : — 

An  irritable  spot  in  the  fossa  navicularis ; 

An  inflamed  hymen  which  has  not  been   ruptured,   or  irritable 

carunculse  myrtiformes ; 

Fissures  in  the  fourchette  or  round  the  vaginal  orifice ; 
Small  ulcers  within  the  hymen  ; 
Fissure  of  the  aims  ; 
Urethral  caruncle. 

SYMPTOMS  AND  DIAGNOSIS. 

Dyspareunia  and  sterility  are  the  leading  symptoms. 

By  dyspareunia  (a  term  introduced  by  Barnes),  we  understand  painful  Dyspar 
or  difficult  sexual  intercourse ;   hence  the   conditions   which  produce euma" 
vaginismus  arise  on  the  patient's  entering  married  life.     The  suffering 
may  be  so  great  that  medical  advice  is  at  once  sought ;  often  a  sense  of 
delicacy  prevents  this  till  the  condition  has  existed  some  time. 

In  some  cases  there  is  a  care-worn  and  anxious  expression  of  counten- 
ance, in  others  a  hysterical  manner.  As  the  ordinary  vaginal  examina- 
tion is  painful — the  patient  involuntarily  drawing  away  as  soon  as 
the  painful  spot  is  touched — it  is  best  to  make  inspection  of  the  genitals 
first.  Here  we  may  see  any  of  the  conditions  mentioned  under  Path- 
ology. Sometimes  no  local  cause  is  evident ;  but  on  carrying  the  finger 
into  the  vagina  the  reflex  contraction  of  the  muscle  is  felt. 

Hildebrandt  has  shown  that  this  muscular  contraction  is  sometimes 
noticed  in  the  upper  part  of  the  vagina,  and  is  then  due  to  spasm  of  the 
levator  ani.  Henrichsen  found  well-marked  contraction  of  the  levator 
ani  in  one  case ;  he  refers  it  to  the  anterior  portion  of  the  muscle  which 
springs  from  the  pubes  and  passes  to  the  vagina  near  the  vulva. 

The  possibility  that  the  dyspareunia  may  be  due  to  some  local 
pathological  condition  at  the  roof  of  the  vagina  (prolapsed  ovary  or 
cellulitis)  and  not  at  the  ostium,  should  be  kept  in  mind. 

The  prognosis  as  to  cure  is  good.  From  the  distressing  nature  of  the 
symptoms,  and  the  relief  obtained  by  the  means  to  be  described,  they 
prove  very  satisfactory  cases  for  treatment. 

TREATMENT. 

First  remove  any  cause  of  local  irritation,  as  urethral  caruncle  or 
irritable  carunculse  myrtiformes ;  in  some  cases  it  is  necessary  to  clip 
away  carefully  the  whole  hymen.  Divide  the  base  of  irritable  fissures 
of  the  anus  with  the  knife,  or  touch  them  with  the  actual  cautery, 
lodoform  in  powder  or  made  into  an  ointment,  is  the  best  local  applica- 
tion to  allay  irritation  or  favour  healing.  Its  penetrating  and  disagree- 
able odour  makes  many  patients  object  to  it.  This  is  diminished  by 


532  AFFECTIONS  OF    VAGINA 

keeping  Tonquin  beans  in  the  powder,  and  by  adding  oil  of  eucalyptus 
or  citronelle  (10  m.  to  §i)  to  the  ointment  or  pessary. 

R  lodoform.  gr.  x. 

Olei  eucalypti  M.  i. 

Fiat  pessarium.  Mitte  tales  xii. 
Sig.  As  directed. 

Cocaine,  5-20  p.c.  solution  or  ointment,  is  also  useful. 

After  the  cause  has  been  removed,  the  ostium  vaginae  must  be  dilated. 
This  is  best  effected  by  making  the  patient  wear  a  vaginal  dilator  night 
and  morning,  for  an  hour  at  a  time  ;  it  may  be  made  of  wood  or  of  glass, 
and  should  have  a  bulbous  end  about  1^  in.  long.  The  conical  form  is 
not  good.  The  pain  caused  by  the  introduction  passes  off  after  a  time. 
Dilators  of  gradually  increasing  size  should  be  used. 

If  the  dilator  cannot  be  worn,  we  must  have  recourse  to  Sims'  opera- 
tion. In  some  cases,  when  the  vaginismus  is  evidently  due  to  the 
narrowness  of  the  ostium  and  specially  when  a  reflex  contraction  of  the 
muscle  is  noted,  this  operation  is  done  without  previous  use  of  the 
dilators. 

Sims'  operation  for  vaginismus.     We  have  already  seen  (p.  10)  that  the 

Sims' .        bulbo-cavernosi  muscles  embrace  the  ostium  vaginae  and  form  a  kind  of 

operation.  ° 

sphincter  for  it ;  their  position  is  seen  in  fig.  7.     To  divide  the  super- 
ficial fibres  of  this  muscle  is  the  aim  of  the  operation. 

The  patient  being  under  chloroform,  two  fingers  of  the  left  hand  are 
passed  into  the  vagina  so  as  to  stretch  the  ostium.  With  an  ordinary 
scalpel,  an  incision  is  made  on  each  side  of  the  fourchette ;  the  incision 
is  about  2  inches  long,  and  extends  from  ^  an  inch  above  the  ostium 
to  the  raphe  of  the  perineum.  The  ostium  is  now  thoroughly  and  firmly 
plugged  with  lint  which  is  kept  in  place  with  a  T-bandage  ;  thorough 
plugging  is  essential  as  there  is  often  smart  haemorrhage  from  the 
incisions.  Next  day  the  lint  is  removed  and  a  glass  dilator  introduced, 
which  must  be  worn  for  one  or  two  hours  night  and  morning  during  a 
period  of  several  weeks. 

Instead  of  dividing  the  sphincter  with  the  knife,  it  may  be  forcibly 
stretched  with  the  fingers  till  the  muscular  fibre  is  ruptured.  This  is 
done  by  passing  the  thumbs  (Tilt)  or  several  fingers  (Heyar)  of  each 
hand  into  the  ostium,  and  then  forcibly  separating  them  till  we 
feel  the  muscular  fibre  yield  under  the  traction.  The  advantage  of  this 
method  is  that  it  is  bloodless  and  there  is  no  granulating  wound  left  to 
heal. 

With  these  local  measures,  we  should  always  combine  constitutional 
treatment.  Exercise,  fresh  air  and  change  of  scene  are  beneficial.  It  is 
self-evident  that  complete  rest  to  the  sexual  system  must  be  strictly 
enjoined  during  any  course  of  local  treatment  •  this  should  be  main- 


TUMOURS.  533 

tained  for  some  time  afterwards,  which  may  be  secured  by  recommend- 
ing a  few  weeks'  residence  from  home.  Tonics  (such  as  quinine,  iron 
and  arsenic)  are  given  as  the  case  requires. 

TUMOURS   OP    THE   VAGINA. 

Under  tumours  of  the  vagina  we  briefly  describe  the  following  :— 
Cysts, 

Fibroid  tumours, 
Carcinoma, 
Sarcoma, 
Tuberculosis. 

Syphilitic  ulceration  does  not  call  for  special  description.  Lipoma 
has  also  been  described.1 

CYSTS   OF   THE   VAGINA. 

LITERATURE.  Breisky— Die  Krankheiten  der  Vagina,  S.  130  :  Stuttgart,  1879.  DeSintty 
—Manuel  pratique  cle  Gynecologic,  p.  164 :  Paris,  1879.  Fischel— Casuistischer 
Beitrag  zur  Lehre  von  den  Scheidencysten  :  Archiv  f.  Gyn.,  XXXIII.,  S.  121. 
Grafe— Zehn  Fiille  von  Vaginalcysten  :  Zts.  f.  Geb.  u.  Gyn.,  Bd.  VIII.,  S.  460. 
Johnston— A  Contribution  to  the  Study  of  Cysts  of  the  Vagina  :  Americ.  Jour,  of» 
Obstet.,  1887,  pp.  1121,  1241.  Lebedeff—  Beitrag  zur  Lehre  uber  Vaginalcysten: 
Zts.  f.  Geb.  u.  Gyn.,  Bd.  VIII.,  S.  324.  Mundt— Case  of  Cyst  of  the  Vagina : 
Americ.  Jour,  of  Obstet.,  vol.  X.,  p.  673.  Veil— Ueber  einen  Fall  von  sehr  grosser 
Scheidencysten:  Zts.  f.  Geb.  u.  Gyn.,  Bd.  VIII.,  S.  471.  Von  Preuschen— Ueber 
Cystenbildung  in  der  Vagina:  Virchow's  Archiv,  Bd.  LXX.,  S.  3.  Johnston's 
paper  discusses  fully  the  literature  of  the  subject.  See  also  Index  of  Literature  in 
Appendix. 

Pathology.  They  are  situated  most  frequently  in  the  anterior  vaginal 
wall,  and  usually  in  the  lower  third  but  within  the  ostium.  They  are 
generally  single,  rarely  have  two  or  more  been  found  together.  They 
are  lined  with  a  single  layer  of  cylindrical  epithelium  which  contrasts 
with  the  many  layers  of  squamous  epithelium  of  the  vaginal  mucous 
membrane  from  which  they  lie  separate  (fig.  316).  We  have  seen  them 
of  the  size  of  a  hen's  egg.  Their  contents  vary  from  a  clear  thin  fluid 
to  a  gelatinous  chocolate-coloured  inspissated  mucus.  Fischel  and 
others  have  also  found  cysts  lined  with  an  endothelium,  and  the  former 
has  demonstrated  their  connection  with  the  lymphatics ;  these  cysts, 
which  must  be  regarded  as  dilated  lymphatics,  are  much  rarer  than 
those  lined  with  cylindrical  or  pavement  epithelium.  Cheron2  found  a 
calculus  in  a  cyst  of  the  anterior  wall,  which  communicated  with  the 
urethra ;  he  refers  to  observations  by  Priestley,  Simon  and  others,  of 
vaginal  cysts  associated  with  urethrocele,  and  would  account  for  this 
condition  by  the  coalescence  of  a  cyst  with  the  urethra, 

Etiology.      As  there  are  hardly  any  mucous  glands  present  in  the 

»  Conrad—  Cent.f.  Gyn.,  XII.,  S.  214.  "  Archiveide  Toe.,  1887,  p.  539. 


534 


AFFECTIONS  OF    VAGINA. 


vaginal  mucous  membrane,  the  mode  of  origin  of  these  cysts  is  disputed. 
In  some  cases  they  can  be  traced  to  crypt-like  depressions  of  the  mucous 
membrane  which  become  shut  off  (Von  Preuscheri).  It  has  been  sug- 
gested by  Veit  that  they  are  due  to  persistence  of  the  canals  of  Gartner, 
rudimentary  structures  which  run  alongside  of  the  uterus  and  vagina 
(cf.  PI.  XI.,  and  p.  227).  They  may  also  be  developed  from  one 
duct  of  Miiller,  a  condition  similar  to  Septate  Vagina  (v.  p.  523)  ;  they 
have  then  the  same  structure  as  the  vagina.  A  case  of  suppurating 
hydatid  of  the  vagina  has  been  recorded  by  Porak.1  Thorn  2  accounts 
for  some  cysts  by  traumatic  blood  and  lymph  extravasations. 

Symptoms.  These  are  often  nil ;  and  such  cysts  readily  escape  obser- 
vation, so  that  they  may  be  more  frequent  than  is  supposed.  When  of 
large  size,  they  produce  bearing  down  pain  with  leucorrhoea  and  in  some 
cases  dyspareunia. 

Diagnosis.     Small  cysts  readily  escape  detection.     When  large,  their 


FIG.  310. 

SECTION  OF  VAGINAL  CYST  (Schroeder).  The  cyst  wall  which  is  lined  with  a  single  layer  of  epi- 
thelium is  separated  by  some  tissue  from  the  mucous  membrane  which  is  covered  with  many 
layers  of  squamous  epithelium  not  detailed  in  the  section. 

smooth  elastic  surface  and  fluctuation  make  them  easily  recognised. 
They  must  not  be  confounded  with  cysts  due  to  obstructed  Bartholinian 
glands,  which  are  situated  on  the  labia  minora  or  at  the  ostium.  Care- 
ful examination  will  easily  distinguish  them  from  a  pouching  of  the 
bladder  or  rectum. 

Treatment.  This  consists  in  laying  the  cyst  open  and  destroying  its 
lining  wall,  which  is  best  done  by  the  cautery.  Schi'oeder  cuts  out  a 
portion  of  the  cyst  wall,  and  stitches  the  margins  of  the  rest  to  the 
adjoining  vaginal  mucous  membrane  so  that  the  cyst  is  taken  up  into 
the  vagina  ;  this  does  away  with  the  granulating  surface  and  subsequent 


1  Archiv.  de  Tocoloy.,  18S4,  p.  163. 


Centralb.f.  Gyn.,  1889,  S.  658. 


TUMOURS.  535 

cicatrisation  which  accompany  cauterisation.  If  the  patient  is  past 
the  menopause  and  the  cyst  gives  no  trouble,  there  is  no  occasion  to 
interfere. 

FIBROID    TUMOURS    OF    THE   VAGINA. 

LITERATURE.  Breisky — Die  Krankheiten  der  Vagina :  Stuttgart,  1879,  S.  139.  A.  R. 
Simpson — Fibroma  Vaginae,  Contributions  to  Obstetrics  and  Gynecology,  p.  201 : 
Edinburgh,  1880. 

Pathology.  Fibroid  tumours  rarely  originate  in  the  vagina  ;  Breisky 
has  collected  only  37  cases  out  of  the  literature.  Michie  x  has  recently 
recorded  a  case  but  gives  no  microscopic  examination  of  the  tumour. 
Like  fibroid  tumours  of  the  uterus,  they  consist  chiefly  of  fibrous  tissue 
with  some  unstriped  muscular  fibre  ;  they  are  usually  situated  in  the 
anterior  wall,  in  17  out  of  27  cases  (A.  R.  Simpson) ;  they  are  pedicu- 
lated  (forming  so-called  fibrous  polypi)  or  sessile. 

Symptoms.  These  are  produced  only  when  the  tumour  is  large.  In 
the  case  described  by  A.  R.  Simpson,  in  which  the  tumour  was  the  size 
of  two  fists,  it  interfered  with  micturition  and  the  escape  of  the  uterine 
discharges. 

Diagnosis.  This  is  easy,  except  in  the  case  of  large  tumours  when 
the  pedicle  is  difficult  to  reach.  The  relation  of  the  bladder  should 
always  be  carefully  ascertained  by  passage  of  the  sound. 

Treatment  consists  in  division  of  the  capsule  and  enucleation  of  the 
tumour  when  it  is  sessile,  or  ligature  and  division  of  the  pedicle  when 
it  is  pediculated. 

CARCINOMA   OF    THE    VAGINA. 

LITERATURE.     Breisky-Die  Krankheiten  der  Vagina,  Billroth's  Handbuch  :  Stuttgart, 
1879   S   15].     Bruckner— Der  primare  Scheidenkrebs  und  seine  Behandlung  :  Zeit 
schri'ft'fiir  Geburtshiilfe  und  Gynak.,  B.  VI.,  Hft.  1,  S.  110.     GWe«-Boston 
Gyn    Jour.,    vol.    VI.,    p.    383.      Kiistncr— Ueber  den  primaren    Scheidenkrel 
Arcliiv  f.  Gynak.,  Bd.   IX.,   S.  279.     Parry-Primary  Cancer  of  Vagina:  Amer. 
Jour,  of  Obstet.,  vol.  V.,  p.  163:  and  Philad.  Med.  Jour.,  Feb    1873      Simpson, 
A.  £.— Contributions  to  Obstetrics  and  Gynecology,  p.  205  :  Edinburgh,  1880.     , 
also  Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

Pathology.  Primary  carcinoma  occurs  very  rarely  in  the  vagina— in 
14  out  of  8287  cases  (Beigel] ;  in  the  paper  cited  above,  Kiistner  has 
collected  but  28  cases  out  of  the  whole  literature.  This  is  the  more 
surprising  when  we  remember  how  very  frequently  it  affects  the  cervix. 
It  occurs  in  two  forms,  either  as  a  localised  broad-based  papillary  swell- 
ing seated  most  frequently  in  the  posterior  wall  or  as  a  diffuse  infiltra- 
tion which  often  constricts  the  canal  in  a  ring-like  manner, 
incminal  glands  are  generally  enlarged  by  carcinomatous  mfiltrati 

Symptom,  and  Diagnosis.     As  in  carcinoma  of  the  cervix,  the* 
hemorrhage  and  foetid  discharge  :  the  pain  is  slight  in  the  early  stage. 

i  Brit.  Med.  Journ.,  1S84,  I.,  1154. 


536  AFFECTIONS  OF   VAGINA. 

The  diagnosis  that  there  is  primary  carcinoma  of  the  vagina  is  often 
doubtful,  because  it  is  difficult  to  ascertain  the  condition  of  the  cervix 
and  uterus  ;  in  the  specimen  represented  at  fig.  281  it  was  supposed 
to  be  primary  until  the  post-mortem  showed  that  it  was  secondary  to 
carcinoma  of  the  cervix.  The  examination  per  rectum  is  useful  in  these 
cases. 

Treatment.  This  consists  in  the  removal  of  as  much  as  possible  of 
the  diseased  tissue  with  the  cautery,  spoon,  or  knife.  Bruckner  recom- 
mends that,  where  possible,  the  wound  produced  by  extirpation  of  the 
carcinomatous  mass  be  closed  by  deeply  placed  sutures.  Riiter  *  records 
a  case  of  non-recurrence  for  three  years  after  removal. 

SARCOMA   VAGINA 

LlTEKATUEE.  Breisky — Die  Krankheiten  der  Vagina :  Billroth's  Handbuch,  S.  150. 
Mann — Sarcoma  of  the  Vagina  :  Amer.  Jour,  of  Obst.,  vol.  VIII.,  p.  541.  Simpson, 
A.  R. — Contributions  to  Obstetrics  and  Gynecology,  p.  204  :  Edin.  1880.  Smith — 
Amer.  Jour,  of  Obst.,  vol.  III.,  p.  671.  Spiegelberg — Zu  den  Sarkomen  des  Uterus 
und  der  Scheide :  Arch.  f.  Gyn.,  Bd.  IV.,  S.  344.  See  also  Index  of  Recent  Gyne- 
cological Literature  in  the  Appendix. 

Sarcoma  of  the  vagina  has  only  recently  been  described,  and  is  still 
rarer  than  sarcoma  uteri.  It  may  arise  very  early  in  life,  being  some- 
times apparently  congenital.2  As  in  the  uterus,  it  is  either  diffuse  or 
in  circumscribed  nodules  (v.  fig.  297).  The  symptoms  are  the  same  as 
in  sarcoma  uteri ;  and  the  treatment  consists  in  removal  (more  easily 
effected  in  the  circumscribed  form),  which  in  a  case  reported  by 
Spiegelberg  effected  a  permanent  cure. 

A  case  came  under  our  notice  in  which  the  patient  died  from  bleeding 
within  fifteen  weeks  after  the  tumour,  the  size  of  a  walnut,  first  attracted 
attention.  It  was  situated  on  the  posterior  wall,  and  the  free  bleeding 
was  probably  due  to  the  venoiis  plexuses  being  eaten  into.  The  case  is 
reported  by  Simmons,3  and  Plate  XIII.,  fig.  3,  taken  from  his  paper, 
shows  a  section  of  the  tumour.  Schuckhardt  4  has  recorded  three  cases 
of  operation  for  its  removal  in  children  under  eight  years  of  age,  with 
the  result  that  one  was  still  without  return  after  two  years ;  a  second 
died  from  recurrence,  while  the  third  was  operated  on  again  for  recur- 
rence. 

TUBERCULOSIS    VAGINA. 

LITERATURE.  Slob— Patholog.  Anat.  d.  weibl.  Sexualorgane,  S.  432:  Wien,  1864. 
Descharnps — Etudes  sur  quelques  ulcerations  rares  et  non  veneViennes  de  la  vulve  et 
du  vagin  :  Archiv.  de  Tocolog.,  1885,  p.  19.  Hegai — Die  Enstehung,  Diagnose,  und 
chirurgische  Behandlung  der  Genitaltuberculose  des  Weibes  :  Stuttgart,  1886. 

It  is  only  of  importance  as  part  of  a  general  affection,  to  be  treated 
constitutionally.  Hegar  divides  it  into  primary  and  secondary  :  the 

1  Bin  Fall  von  Carcinom  der  Scheide :  Central!),  f.  Gyn.,  XI.,  S.  606. 

2  As  in  a  case  of  Graenicher's  where  a  tumour  was  first  noticed  shortly  after  birth,  removed  at  15 
months,  and  recurred  at  4th  year.     Ccntralb.f.  Gyn.,  XIII.,  S.  591. 

3  Rare  cases  of  malignant  disease  of  the  Female  Sexual  Organs  :  Edin.  Med.  Journ.,  Dec.  1885. 
«  Ueber  Sarkom  der  Scheide:  Archiv  f.  Gyn.,  XXXII.,  S.  400. 


Hsemorrhages 


^ >v~  SHb 


>    ' 


Fig.  2.  Section  of  Epithelioma  of  Labia— stained  picrocarmine  (  X  50) 


Extravasated  blood 


Connective  tissue 


J.  Tatham  Thompson 
(del.  ad.  not.) 


Fig.  3.  Section  of  Ham>ina  of  Vagina  :  stained  picrocarmine  (x 


PLATE  XIV. 


Cell- nests  in  section 

K 


Connective  tissue 


Venous  sinus 


pig.  1.  Section  of  Epithelioma  of  Clitoria-fltained  picrocarmine  (  X  40) 


TUMOURS.  537 

former  is  specially  liable  to  arise  after  labour  when  the  tissues  are  soft 
through  direct  infection  from  instruments,  examining  fingers  or  coitus  ; 
the  latter  takes  place  through  the  blood,  or  from  the  outside,  e.g.,  by 
germs  from  the  stools.  Barbier  J  says  that  the  bacilli  may  be  either  in 
the  seminal  fluid  itself  or  in  the  discharge  from  a  tubercular  epididy- 
mitis.  Zweigbaum, "  in  reporting  a  case  of  primary  tuberculosis  of  the 
cervix  and  vagina  with  secondary  of  the  lung  and  intestines,  has 
collected  twenty-nine  cases  of  tuberculosis  of  vagina  and  cervix. 

1  fffu.  Meil.,  1SSS,  Xo.  39.  2  Brit.  Mid.  /own.,  1889, 1.,  p.  93. 


SECTION  VII. 

AFFECTIONS  OF  THE  VULVA  AND  PELVIC  FLOOR. 

CHAPTER  XL VII.  The  Vulva  :  Malformations  j  Inflammation ;  Tumours. 
XLVIII.  Rupture  of  the  Perineum  and  its  Operative  Treatment. 
XLIX.  Displacements  of  the  Pelvic  Floor :  Prolapsus  Uteri ; 
Enterocele. 


CHAPTER    XLVII. 

THE  VULVA:   MALFORMATIONS;   INFLAMMATION; 
TUMOURS. 

LITERATURE. 

MALFORMATIONS.  Hildebrandt — Die  Krankheiten  der  ausseren  weiblichen  Genitalien : 
Stuttgart,  1877,  S.  2.  Meyer— Virchow's  Archiv.,  XI.,  p.  420.  Schroeder— Die 
Krankheiten  der  weiblichen  Geschlechtsorgane,  S.  497 ;  Leipzig,  1879.  Simpson, 
Sir  J.  Y. — Hermaphroditism  :  Collected  "Works,  vol.  II.,  p.  407.  Tail,  Lawson — 
Am.  Gyn.  Trans.,  vol.  I.,  p.  318. 

INFLAMMATION.  Hildebrandt — Op.  cit.,  S.  17  and  64.  Simpson,  Sir  J.  Y. — Diseases  of 
"Women,  p.  286.  Thomas— Diseases  of  Women,  p.  122  :  London,  1880. 

TUMOURS.  Breisky  —  Ueber  Kraurosis  vulvse,  cine  wenig  beachtete  Form  von  Haut- 
atrophie  am  Pudendum  muliebre  :  Zeitsch.  fur  Heilkunde,  vi.  69.  Also  Centralb.  f . 
Gynak.,  1885,  359.  Deschamps — Epithelioma  primitif  de  la  vulve;  Esthiomene : 
Archiv.  de  Tocologie,  1885,  pp.  120,  221.  Duncan,  J.  Matthews — On  the  Hyper- 
trophy of  Lupus  of  the  Female  Generative  Organs  :  Lond.  Obst.  Tr.,  1885,  p.  230. 
See  also  Ed.  Med.  Jour.,  July  1884,  and  Clinical  Lectures,  1886.  Duncan,  J.  M. 
and  Thin — On  the  Inflammation  of  Lupus  of  the  Pudendum :  London  Obst.  Tr., 
1885,  p.  310.  Hildebrandt— Op.  cit.  Chap.  VII.,  where  the  student  will  find 
the  literature  of  the  various  forms  of  tumour  fully  given.  Huguier — Memoire 
sur  1'Esthiomene  :  Memoires  de  1'academie  de  Medecine,  t.  XIV.,  p.  508.  Kustner — 
Zur  Pathologie  und  Therapie  des  Vulvacarcinoms  :  Zeitsch.  f.  Geb.  \\.  Gyn.,  1882,  70. 
Lomei — Zur  Casuistik  des  Carcinoms  der  Vulva :  Ztschrift.  f.  Geb.  u.  Gyn.,  1882, 
167.  MacDonald,  Angus — Lupus  of  the  Vulvo-anal  region,  with  cases :  Ed.  Obst. 
Tr.,  IX.,  49.  Peckham — A  Contribution  to  the  Study  of  Ulcer  Lesions  of  the  Vulva  : 
Am.  Journ.  Obst.,  1887,  p.  785.  Simmons — Rare  cases  of  Malignant  Disease  of  the 
Female  Sexual  Organs :  Ed.  Obst.  Tr.,  X.,  202.  Tait,  Laicson — Climacteric 
Diabetes  in  Women :  Practitioner,  June  1886.  Taylor,  J.  E. — Lupus  or  Esthio- 
mene of  the  Vulvo-anal  region  :  Am.  Gyn.  Tr.,  VI.,  199.  Zweifel — Die  Krankheiten 
der  ausseren  weiblichen  Genitalien  und  die  Dammrisse :  Handbuch  der  Frauen- 
Krankheiten,  Billroth  and  Luecke,  Bel.  III.,  Stuttgart,  1886.  See  also  Index  of 
Recent  Gynecological  Literature  in  the  Appendix  for  all  of  these  subjects. 

MALFORMATION  S. 

Develop-  THESE  are  easily  understood  when  we  remember  the  normal  develop- 
ment of  the  external  organs  of  generation.  1.  At  the  sixth  week  of 
foetal  life,  the  genital  eminence  appears  externally ;  at  this  period  the 
rectum,  allantois  and  ducts  of  Miiller  communicate  with  one  another 
but  not  with  the  exterior  (fig.  317).  2.  At  the  tenth  week  a  depres- 
sion of  the  skin  (known  as  the  genital  cleft}  occurs  ;  this  extends  inwards 
till  it  meets  the  conjoined  allantois  and  rectum,  and  thus  the  cloaca  is 
formed  (fig.  318).  3.  The  tissue  between  the  rectum  and  the  allantois 
grows  downwards,  and  divides  the  cloaca  into  an  anterior  part  (the  uro- 


MALFORMATIONS  OF   VULVA. 


541 


genital  sinus,  into  which  the  ducts  of  Miiller  open)  and  a  posterior  part 
(the  anus) :  thus  the  perineum  is  formed  (figs.  319  and  320).  4.  The 
uro-genital  sinus  contracts  in  its  upper  portion  to  form  the  urethra, 
while  the  lower  part  persists  as  the  vestibule  (fig.  321) ;  the  ducts  of 
Miiller  coalesce  to  form  the  vagina  (y.  p.  73). 


OJ 

FIG.  317. 

R  rectum  continuous  with  All  allantois  (bladder) 
and  M  duct  of  Miiller  (vagina),  x  Depres- 
sion of  skin  below  genital  prominence  which 
grows  inwards  and  forms  vulva  (Schroeder). 


FIG.  318. 

The  depression  has  extended  inwards  and 
becoming  continuous  with  the  rectum  and 
allantois,  formed  the  cloaca  el  (Schroeder). 


The  parts  round  the  vulva  develop,  therefore,  as  follows ;  the  clitoris 
from  the  genital  eminence,  the  labia  minora  from  the  margins  of  the 
genital  cleft,  the  vestibule  from  the  uro-genital  sinus. 

The   following    malformations   have   been   described.      1.    Complete  Malforma- 
tions. 


FIG.  319.  FIG-  320. 

The  cloaca  is  becoming  divided  into  uro-genital  The  perineum  is  completely  formed 

sinus  Su  and  anus  by  the  downward  growth  (Schroeder). 

of  the  perineal  septum.  The  ducts  of 
Miiller  have  united  into  the  vagina  V 
(Schroeder). 

atresia  of  the  vulva  through  the  non-formation  of  the  depression  of  the 
skin  (fig.  317);  the  allantois  and  rectum  either  communicate  as  in  fig. 
317  or  have  become  separated.  This  condition  has  only  been  found  in 
fretal  monstrosities.  2.  Persistence  of  a  cloaca  so  that  the  rectum, 


FIG.  321. 

The  upper  part  of  the  uro-genital  sinus  has  contracted  into  the  urethra;  the  lower  portion  pewisto 
as  the  vestibule  Sit  (Schroeder). 

vagina  and  urethra  have  a  common  orifice  (fig.  318);  such  cases  are 
sometimes  spoken  of  as  atresia  of  the  anus  but  are  really  due  to  non- 
formation  of  the  recto-vaginal  septum.  3.  Persistence  of  the  uro-genital 


542       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

sinus  into  which  the  bladder  opens  directly  as  the  urethra  has  not 
formed  (fig.  320);  in  such  cases  the  vulvar  orifice  is  contracted  and 
opens  into  a  long  narrow  vestibule  which,  at  its  farther  end,  communi- 
cates with  the  bladder  and  vagina.  This  condition  is  sometimes 
described  as  hypospadias. 

HERMAPHRODITISM. 

For  a  detailed  description  of  this  condition  with  illustrative  cases,  the 
student  should  consult  Sir  J.  Y.  Simpson's  exhaustive  article  on  Herma- 
phroditism  (Collected  Works,  Vol.  II.,  p.  407).  References  to  recent 
cases  will  be  found  in  the  Index  in  the  Appendix. 


FIG.  322. 


FIG.  323. 


SPURIOUS  HERMAPHRODITISM  (Sir  J.  T.  Simpson). 


Pelvis  of  a  female  infant  in  which  the  external 
organs  simulated  those  of  a  male,  c  Uterus 
and  appendages,  6  hypertrophied  clitoris 
with  a  sulcus  at  its  extremity  a,  which 
ended  blindly,  and  did  not  communicate 
with  the  urethra. 


Case  of  hypospadias  in  the  male,  making  the 
external  organs  simulate  those  of  the 
female.  CM  Lobes  of  scrotum  ;  6  iniperf o- 
rate  penis,  It  inches  long ;  e  perineal 
fissures  1J  inches  deep,  lined  with  mucous 
membrane,  at  bottom  of  which  the  ureth- 
ral  orifice  d  is  seen ;  c  the  split  urethra, 
with  openings  /  of  glands  beside  it — sup- 
posed to  be  orifices  of  prostatic  ducts,  of 
Cowper's  glands,  and  of  seminal  canals. 


Of  hermaphroditism  ( Ep/^s  and  ' A^poSir??)  there  are  two  varieties,  true 
and  spurious. 

True  jjy  frue  hermaphroditism,    we   understand   that  from  the   Wolffian 

phroditism.  bodies  both  ovary  and  testicles  have  developed  so  that  both  forms  of 


MALFORMATIONS  OF   VULVA.  543 

gland  co-exist  in  the  same  individual.  This  is  an  extremely  rare 
occurrence  ;  when  it  has  occurred,  there  is  a  tendency  towards  the  better 
development  of  one  form  of  organ  (determining  the  sex)  while  the  other 
is  rudimentary.  According  to  Hildebrandt  (loc.  cit.,  S.  6),  only  two 
authentic  cases  of  bilateral  hermaphroditism  (ovary  and  testicle  present 
on  each  side)  have  been  recorded ;  of  unilateral  hermaphroditism  (ovary 
and  testicle  present  on  one  side),  the  other  side  having  only  one  form  of 
gland,  a  case  has  been  recorded  by  Bannon ;  lateral  hermaphroditism 
(ovary  on  one  side  and  testicle  on  the  other)  has  been  more  frequently 
met  with  and  cases,  confirmed  by  microscopic  examination,  have  been 
recorded  by  Berthold,  Barkow,  and  Meyer. 

By  false  or  pseudo-hermaphroditism,  is  understood  a  malformation  of  False 
the  external  organs  so  that  they  simulate  those  of  the  opposite  sex.  phroditism. 
This  occurs  in  two  forms.     1.  The  external  organs  in  the  female  may 
simulate  those  of  the  male.     This  is  due  to  a  hypertrophy  of  the  clitoris 
and  its  prepuce,  with  approximation  of  the  labia  majora  (simulating  a 
scrotum)  and  contraction  or  occlusion  of  the  ostium  vaginae ;  in  very 
rare  cases  is  the  clitoris  perforated  by  the  urethral  canal.     This  condi- 
tion is  seen  at  fig.  322,  which  represents  the  pelvis  and  external  organs 
of  an  infant  christened  as  a  boy ;  a  post-mortem  dissection  showed  that 
the  sex  was  female.1 

2.  The  external  organs  in  the  male  may  simulate  those  of  the  female ; 
the  non-closure  of  the  lower  surface  of  the  urethra  and  perineum,  which 
constitutes  hypospadias,  produces  an  appearance  resembling  the  external 
organs  in  the  female.  Numerous  cases  are  on  record  in  which  the  sex  of 
males  has  been  mistaken,  even  by  medical  experts,  and  the  persons  have 
entered  married  life  as  belonging  to  the  female  sex.  The  penis  may  be 
small  and  imperforate,  the  urethra  opening  at  its  base  ;  the  perineal 
fissure,  lined  by  mucous  membrane,  may  closely  resemble  the  vagina ; 
and  the  halves  of  the  scrotum  may  appear  like  labia.  This  condition  is 
seen  at  fig.  323  :  the  case  is  reported  by  Otto  ;2  the  person  lived  in  a 
state  of  wedlock  with  three  husbands  before  the  true  sex  was  ascer- 
tained by  medical  examination. 

Cases  of  epispadias,  in  which  the  urethra  (through  defect  of  the  upper  EpispadiAs 
portion  of  the  penis)  is  exposed  along  with  a  portion  of  the  bladder,  ™r  Herma. 
would  only  on  hasty  examination  be  mistaken  for  the  external  female  phrodit 
organs.     The  exposed  vesical  mucous  membrane  with  its  skin  margins 
resembles  the  vagina  with  the  labia,  but  it  is  situated  above  the  pubis  ; 
further,  below  the  penis  we  find  the  normal  scrotum  and  testicles. 

Diagnosis.     In  examining  a  case,  proceed  as  follows.     1.  Palpate  the 
supposed  labia  carefully  to  ascertain  whether  testicles  are  present  in 
them ;   the  possibility  of  hernia  of  the  ovaries  into  the  labia  and 
non-descent  of  the  testicle  into  the  scrotum,  must  be  kept  m  view. 

i  Ramsbotham-3/ecfecU  Gazette,  XIII.,  p.  184.  *  Sir  J.  Y.  Simpson-^;,  cit.  p.  427. 


544      AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

2.  Examine  per  rectum  for  traces  of  uterus  or  ovaries.  3.  After  puberty 
watch  for  the  menstrual  molimina  or  haemorrhage  in  the  female,  and  for 
development  of  sexual  powers  in  the  male.  4.  Note  secondary  sexual 
characters :  development  of  breasts,  appearance  of  face,  tone  of  voice, 
and  inclination  towards  one  or  other  sex. 

Hermaphroditism,  like  malformations  in  general,  lies  beyond  treat- 
ment. 

INFLAMMATION    OP    THE    VTJLVA    (VULVITIS). 
Varieties.     We  may  have 

Acute  vulvitis, 

Chronic  vulvitis, 

Follicular  vulvitis, 

Erysipelas  or  gangrene, 

Progressive  gangrene  or  progressive  suppuration. 

Pathology.     In  the  acute  stage,  the   mucous  membrane  round  the 

ostium  vaginae  and  urethra  is  red,  swollen  and  painful.     Sometimes  the 

Abscess  of  mucous  glands  are  obstructed,  and  a  form  of  acne  develops ;  the  Bartho- 

linian         linian  glands  may  inflame  and  suppurate,  producing  an  abscess  about 

gland.        tne  sjze  of  a  pigeon's  egg;  the  sebaceous  glands  at  the  roots  of  the  hair 

on  the  labia  majora  are  sometimes  specially  affected,  producing  the 

"  Folliculite  vulvaire  "  of  Huguier,  an  excessively  rare  affection.     In  the 

chronic  stage,  there  is  abundant  secretion  of  creamy  purulent  matter ; 

when  due  to  gonorrhoea,  papillomata  form  round  the  vaginal  orifice. 

Erysipelas  or  gangrene  usually  occurs  after  labour,  or  in  infants  after 

fevers  (J.  M.  Duncan).      Progressive  gangrene  with  destruction  of  parts 

may  occur ;  and  in  old  or  young  women  we  may  get  recurring  boils, 

for  which  Duncan  recommends  rubbing  with  mercurial  ointment. 

Etiology.  It  is  often  secondary  to  vaginitis,  and  accompanies  urinary 
fistula  and  carcinoma.  Want  of  cleanliness  and  protracted  exercise, 
specially  in  hot  weather,  produce  it  and  that  most  readily  in  patients 
with  much  adipose  tissue.  It  is  sometimes  occasioned  by  awkward 
coitus  and  by  masturbation.  In  children,  it  is  not  uncommon ;  it  is 
important  to  remember  this,  as  the  inflamed  appearance  of  the  vulva 
and  the  profuse  discharge  make  the  parents  suspect  that  the  child  has 
been  violated  and  has  contracted  specific  disease.  It  is  caused  by 
irritation  of  urine,  want  of  cleanliness,  and  the  strumous  diathesis ; 
sometimes  it  takes  an  epidemic  form  in  the  children  of  a  family  or 
district.  These  last  are  probably  due  to  speading  of  gonorrhoea1 
through  want  of  cleanliness. 

The  Symptoms  and  Physical  Signs  will  be  apparent  from  what  has 
been  said  under  Pathology. 

1  Pott— Archivf.  Gyn.,  XXXII.,  S.  493. 


PRURITUS    VULVAS.  545 

Treatment.  Strict  attention  to  cleanliness  must  be  enjoined  ;  frequent 
bathing  with  warm  water  and  the  application  of  hot  linseed  poultices 
will  ease  pain.  In  children,  the  pain  in  micturition  is  relieved  by  its 
being  done  while  in  a  warm  bath.  Sedative  lotions  such  as  acetate  of 
lead  and  opium  may  be  required  : — 

R     Tinct.  opii.  =Ss. 

Plumbi  acetat.        3i. 
Aquam  ad  §vi.    M. 

In  chronic  cases,  frequent  washing  with  2  per  cent.  sol.  of  carbolic  or 
with  astringent  lotion  is  necessary.  In  abscess  of  the  glands,  the  pus 
is  evacuated  through  the  gland  ducts  on  pressure,  or  by  free  incision. 
Occasionally  a  gonorrhoea  of  the  duct  of  the  Bartholinian  gland  persists 
so  that  the  duct  requires  to  be  laid  open. 

PRURITUS   VULV.S. 

Definition.  An  irritable  condition  of  the  external  genitals  producing 
excessive  itchiness. 

Pathology.  The  irritable  region  is  at  the  upper  convergent  angle  of 
the  labia  majora  at  the  mons  veneris  ;  it  may  extend  from  that  over  the 
vestibule  and  the  vaginal  orifice,  and  sometimes  over  the  mons  veneris 
on  to  the  abdomen.  The  pathological  changes  in  the  skin  which  produce 
this  irritability  are  not  known,  because  the  cases  are  not  seen  in  an 
early  stage.  By  the  time  that  the  irritation  has  become  so  unbearable 
that  advice  is  sought,  the  skin  is  inflamed  and  excoriated  by  continued 
scratching  which  masks  its  original  condition. 

Etiology.  Any  irritating  discharges  from  the  vagina  as  in  carcinoma, 
and  even  simple  leucorrhcea  as  from  senile  vaginitis,  may  produce  it. 
It  occurs  in  diabetes — due  to  irritation  from  the  sugar  in  the  urine 
(Friedreich] — and  in  affections  of  the  kidney  and  bladder,  just  as  similar 
conditions  produce  irritation  of  the  penis  in  man.  In  children,  it 
accompanies  vulvitis  and  has  been  traced  to  the  passing  of  the  Oxyuris 
Vermiculams  from  the  anus  to  the  vulva.  It  is  also  caused  by  whatever 
produces  congestion  of  the  labia — hence  its  occurrence  at  the  men- 
strual period  and  in  early  pregnancy;  by  irritable  skin  affections 
as  herpes,  eczema,  and  the  parasitic  eczema  marginatum ;  and  by 
pediculi. 

Symptoms.  The  irritation  is  not  continuous  but  recurs  periodically. 
In  some  cases,  it  appears  only  after  taking  a  long  walk  or  after  getting 
warm  in  bed  ;  sometimes  it  is  most  marked  before  the  menstrual  period. 
The  irritability  is  slight  at  first  but  becomes  aggravated  by  scratch- 
ing. To  obtain  this  temporary  relief,  the  patient  gradually  avoids 
company  and  this,  along  with  the  constant  irritation,  has  led  in  some 
cases  to  nervous  depression  and  melancholia ;  sometimes  the  practice  of 
2  M 


546       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

masturbation  is  learned  at  the  same  time,  and  the  consequent  nervous 
symptoms  gravely  complicate  the  case. 

Diagnosis.  As  the  most  hopeful  cases  for  treatment  are  those  in 
which  a  distinct  removable  cause  is  found,  a  thorough  examination  is 
necessary :  (1)  Carefully  inspect  the  external  genitals  for  irritating  skin 
eruptions,  and  examine  scrapings  of  the  affected  parts  microscopically 
for  parasites ;  (2)  expose  the  vagina  and  cervix  thoroughly  with  the 
speculum  to  ascertain  whether  there  is  irritating  leucorrhcea,  the 
plugging  of  the  vagina  with  cotton  wadding  to  check  discharge  from 
the  vagina  or  cervix  will  help  us  to  exclude  this  (Thomas)  •  (3)  test  the 
urine  for  albumen  and  sugar ;  (4)  examine  per  rectum  for  any  source  of 
irritation  there. 

Treatment.     We  must  first  remove  the  cause.     When  parasites  are 

Treatment  present,  the  mercurial  or  sulphur  ointment  is  required  ;  with  vaginal  or 
of  Pruritus.  r 

cervical  catarrh,  a  tampon  of  wadding  and  glycerine  (with  acetate  of 

lead  3ii  to  §i)  in  the  vagina  will  check  the  irritating  discharge.  Atten- 
tion to  diet  (which  should  consist  largely  of  vegetables)  and  to  the 
regular  action  of  the  bowels  is  necessary ;  when  the  gouty  diathesis 
(with  which  pruritus  is  often  associated  in  old  patients)  is  pi-esent,  lithia 
water  is  useful.  It  is  a  safe  rule  to  forbid  all  stimulants.  Frequent 
vaginal  injections  or  sponging  with  warm  water,  followed  by  the  applica- 
tion of  boracic  ointment  or  bismuth,  will  relieve  mild  cases ;  in  more 
severe,  the  patient  should  have,  several  times  a  day,  a  warm  sitz-bath 
combined  with  the  douche ;  after  this,  iodoform  is  dusted  over  the 
vestibule  or,  if  the  patient  is  recumbent,  lint  soaked  in  acetate  of  lead 
and  opium  lotion  is  laid  between  the  separated  labia.  In  some  cases, 
chloroform  and  almond  oil  have  given  relief  (Scanzoni). 

R     Chloroformi  3"- 

Olei  amygdalae  5ii.     M. 

Sig.  Apply  externally  as  directed. 

Preparations  of  mercury  give  benefit  in  other  cases. 

R     Hydrargyri  perchloridi     3ss. 

Aqua?  5vi.     M. 

Sig.     Apply  externally  as  directed. 

Schroeder  has  seen  very  good  results  from  the  application  of  carbolic 
acid  of  varying  strength — 1  to  40  up  to  1  to  10.  Solid  menthol  is  also 
used.  Where  milder  measures  have  failed,  solid  nitrate  of  silver  well 
rubbed  into  the  irritated  parts  and  followed  by  cold  water  dressing  has 
given  relief.  In  parasitic  cases  a  lotion  of  equal  parts  of  sulphurous 
acid  and  glycerine  may  be  used.  To  procure  rest  at  night,  morphina 
and  chloral  may  be  necessary ;  Hildebrandt  has  found  tinct.  cannabis 
Indices  (m.  10-20)  even  more  effective  than  these.  A  4  per  cent. 


TUMOURS  OF   VULVA.  547 

solution  of  cocaine  may  be  tried.     Application  of  galvanic  current  ha< 
been  used  with  success.1 

ERUPTIONS    ON    THE   VULVA. 

The  skin  round  the  vulvar  orifice  may  be  affected  with  any  of  the 
eruptions  found  on  other  parts  of  the  body.  Of  these  the  most 
important  are  erysipelas,  eczema,  prurigo,  herpes,  acne.  These  erup- 
tions have  the  same  character  as  when  they  occur  in  other  situations, 
and  their  treatment  is  the  same.  Condylomata  may  be  found  on  the 
skin,  and  mucous  patches  over  mucous  surfaces.  Eczema  is  frequently 
caused  by  diabetes,  according  to  Lecorche.2  Hebra's  plates  of  Skin 
Diseases  illustrate  these  conditions  very  well ;  see  also  a  paper  in  the 
Annales  de  Dermatologie  et  Syphilographie  for  April  1882,  by  Gougen- 
heim  and  Soyer. 

TUMOURS    OF    THE    VULVA. 
Under  these  we  shall  notice  briefly — 

Cysts  of  the  Bartholinian  glands, 

Elephantiasis, 

Neuroma, 

Fibroma, 

Lipoma, 

Carcinoma, 

Sarcoma, 

Lupus, 

Kraurosis. 

This  is  also  the  most  convenient  place  to  refer  to 

Pudendal  hernia, 

Varix,  hsematoma  and  haemorrhage. 

Cysts  of  the  Bartholinian  glands.     The  Bartholinian  or  vulvo-vaginal  Cysts  and 
glands,   which  are  the  analogue  of  Cowper's  glands  in  the  male,  are^t^ 
situated  at  each  side  of  the  ostium  vaginae  (see  fig.  7);  their  ducts  (about linian 
2  cm.  long  and  wide  enough  to  admit  a  fine  probe)  run  upwards  tog  nt' 
about  the  middle  of  the  ostium  vaginae,  where  their  mouths  may  be  seen 
in  front  of  the  hymen. 

A  cyst  may  form  by  dilatation  of  the  ducts  or  of  the  glands  them- 
selves. When  due  to  distension  of  the  duct,  it  has  at  first  an  elongated 
oval  form  ;  when  the  gland  itself  is  affected,  there  may  be  multiple  cysts 
or  a  lobulated  swelling.  They  generally  occur  on  the  left  side. 3  The 

1  Blackwood,  Polyclinic,  1885,  No.  9  ;  and  v.  Campe,  Central./.  Gyn.,  Bd.  XL,  8.  521. 

2  Du  diabete  dans  ses  rapports  avec  la  vie  uterine,  etc.  :  Annalei  de  Gyn.,  Oct.  1885. 

3  Bonnet—  Gaz.  des  Hopitauj:,  1888,  No.  69. 


548       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

contents  are  thick  mucus,  which  is  clear  or  of  a  brownish  tinge.  Sup- 
puration may  occur  and  abscess  form  (v.  fig.  324). 

The  symptoms  are  due  to  the  discomfort  of  the  swelling,  which  is 
most  felt  on  walking.  The  diagnosis  is  easy,  from  the  position  of  the 
swelling  and  its  fluctuating  character ;  when  it  has  developed  during 
the  puerperium,  we  must  differentiate  it  from  hsematoma  (which  after  a 
time  becomes  firm  from  coagulation)  and  inflammation  after  injury. 

The  treatment  consists  in  complete  evacuation  of  the  cyst  and 
destruction  of  its  walls.  It  is  not  sufficient  to  open  it  and  allow  the 
fluid  to  escape ;  we  must  cut  out  a  portion  of  the  wall  and  then  plug 
the  cyst  with  antiseptic  lint.  By  far  the  best  instrument  is  the  thermo- 
cautery :  we  first  puncture  the  cyst  with  it ;  when  the  fluid  has  escaped, 
we  pick  up  the  outer  cyst  wall  with  forceps  and  lay  it  fairly  open  with 


FIG.  324. 

ABSCESS  OF  THE  BARTHOLINIAN  GLAND  (Huguier). 

the  cautery ;  we  then  cauterise  the  inner  wall  also.     A  piece  of  anti- 
septic lint  is  laid  over  the  wound. 

Cysts  also  occur  in  the  labia  minora ; *  they  are  very  rare  and  their 
pathology  is  not  known. 

Elephant!-  Elephantiasis.  This  is  a  common  condition  in  tropical  countries,  but 
is  comparatively  rare  in  Europe  and  America  although  a  minor  degree 
of  it  is  occasionally  met  with. 

The  pathological  changes  consist  in  a  dilatation  of  the  lymphatic 
spaces  and  ducts,  with  secondary  formation  of  connective  tissue  and 
thickening  of  the  layers  of  the  cutis  vera ;  sometimes  the  papillae  are 
specially  enlarged,  producing  swellings  which  resemble  condylomata  in 
form.  The  labia  majora  are  most  frequently  affected,  next  in  frequency 
the  clitoris ;  more  rarely  are  the  labia  minora  hypertrophied  (Mayer). 

1  Smith  removed  two  such  cysts  :  Brit.  Med.  Journ.,  1888,  I.,  250. 


TUMOURS   OF    VULVA.  549 

It  develops,  according  to  Mayer,  most  frequently  at  ages  of  from  20 
to  30  years— that  is  in  the  period  of  sexual  activity.  It  has  been  traced 
to  direct  injury,  but  the  most  fruitful  cause  of  minor  degrees  of  hyper- 
trophy is  syphilis. 

The  symptoms  are  due  to  the  weight  and  discomfort  of  the  tumour 
which  may  reach  to  the  knees.  For  drawings  of  the  various  forms, 
Esmarck  and  Kulenkampff's  monograph  Die  Elephantiaschenformen 
(Hamburg  1885)  may  be  consulted.  The  treatment  of  the  larger 
growths  is  removal  with  the  thermo-cautery. 

Neuroma,    an   exquisitely  sensitive  red   papule   which   resembles   a  Neuroma, 
urethral  caruncle,  has  been  described  by  Sir  J.  Y.  Simpson  (see  fig.  353); 
its  occurrence,  except  at  the  urethral  orifice,  is  extremely  rare. 

Fibroma.     This  springs  from  the  labia  majora,  resembles  in  structure  Fibroma, 
fibroid  tumours  of  the  uterus,  and,  like  them,  is  embedded  in  cellular 
tissue  or  hangs  down  by  a  pedicle.    Taylor  has  reported  a  case  of  fibroid 
of  the  vestibule.1 

Lipoma  may  arise  from  the  fatty  tissue  of  the  mons  veneris  or  labia  Lipoma. 
majora.     Emmet 2   describes  a  case  in  which  the  tumour  hung  down  to 
the   patient's   knees  and  was  supported   in  a  bag  round  the   waist; 
Stiegele3  removed  one  which  weighed  10  Ibs. 

Carcinoma  of  the  vulva  is  rare  in  comparison  with  its  frequency  in  Carcinoma, 
the  uterus.  In  16,637  cases  of  tumours  of  the  female  sexual  organs, 
Gwilt  found  that  7479  were  cancerous ;  and  of  these,  72  (or  1  per  cent.) 
were  vulvar.  The  most  frequent  form  is  the  cancroid  ( West}.  It  begins, 
usually  on  the  inner  surface  of  the  labia  majora,  as  small  round  nodules 
which  elevate  the  skin ;  they  may  remain  for  a  long  time  unnoticed,  as 
their  growth  is  at  first  slow  and  painless.  After  ulceration  they  spread 
more  rapidly,  and  extend  forwards  and  backwards  but  rarely  into  the 
vagina.  The  section  of  such  a  nodule  is  shown  in  Plate  XIII.  fig.  2. 
It  is  important  to  diagnose  it  from  lupus,  which  may  so  closely  resemble 
it  that  certainty  is  only  got  by  microscopic  examination.  The  inguinal 
glands  are  early  involved. 

Complete  removal  before  the  glands  are  affected,  is  the  only  treat- 
ment. As  the  growth  is  accessible,  there  seems  a  prospect  of  cure  ; 
during  the  last  few  years  cases  are  reported  by  Schroeder  and  others 
of  extirpation  without  recurrence,  but  the  time  elapsed  is  too  short  to 
justify  definite  conclusions.  Kustner  has  advocated  removal  of  the 
inguinal  glands  of  the  affected  side  if  these  are  larger  than  those  on 
the  healthy  side. 

Plate  XIII.  fig.  1  shows  a  section  of  an  interesting  case  of  epithelioma 
of  the  clitoris  reported  by  Simmons.  In  the  position  of  the  clitoris, 
there  was  an  irregular  nodular  mass  with  a  soft  friable  centre  and  indu- 

>  Amerit.  Journ.  Obxtet.,  1888,  p.  434.  *  Op.  eit.,  p.  601. 

••>  Zeits.f.  Chir.  u.  Geb.,  Bd.  IX.,  S.  243. 


550       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

rated  prominent  uneven  margins.  The  growth  was  removed  by  A.  R. 
Simpson ;  wire  sutures  were  passed  underneath  the  tumour  which  was 
then  cut  away,  bleeding  points  tied  with  catgut  and  the  margins  of  the 
wound  drawn  together  with  the  sutures.  Primary  epithelioma  of  the 
clitoris  is  a  rare  condition ;  only  five  other  cases  are  given  in  Simmons' 
paper. 

Sarcoma  of  the  vulva  is  very  rare.  Geith  and  Terrillon1  have  recorded 
cases  of  melanotic  sarcoma.  Haeckel  has  collected  10  cases  of  melan- 
otic  tumours,2  mostly  sarcomatous. 

Lupus  Lupus  vulvce  is  a  condition  drawn  attention  to  by  Huguier,  West, 

vse>  Taylor,  Matthews  Duncan,  Macdonald,  and  Peckham.  Duncan  has 
recently  considered  it  very  fully,  and  an  able  histological  examination  of 
his  specimens  has  been  made  by  George  Thin.  It  may  be  defined  as  a 
slow  chronic  hypertrophic  condition  of  the  pudenda,  prone  to  ulcerate 
and  erode,  causing  little  pain,  lasting  long,  and  not  infecting  neigh- 
bouring glands  or  causing  ill-health. 

Pathology.  As  to  its  pathology,  it  is  a  hypertrophic  condition  with  tendency  to 
ulcerate  and  cause  stricture  of  urethra,  vagina,  or  rectum.  Pus  is 
secreted  by  the  ulcerated  surface,  and  occasionally  considerable  destruc- 
tion of  parts  is  caused.  The  hypertrophy  may  be  small  (lupus  mini- 
mus), large  (lupus  hypertrophicus),  or  forming  irregular  masses  extending 
to  the  hip.  Other  terms  have  been  used,  viz.,  lupus  prominens,  lupus 
serpiginosus  ;  it  was  termed  by  Huguier,  "Herpes  1'Esthiomene." 

Micro-  On  microscopic  examination,  Thin    found   growth   of  fibrous  tissue 

Examina-    (ordinary  white  fibrous  tissue)  and  absence  of  any  neoplastic  structure ; 

tion.  exudation  cells  were  also  present.  Blood-vessels  were  unusually  nume- 
rous. The  appearances  thus  differ  from  lupus  vulgaris,  cancer,  or 
syphilis  ;  they  are  somewhat  analogous  to  elephantiasis,  but  differ  from 
that  condition  in  the  non  -  implication  of  the  lymphatics  and  the 
presence  of  inflammatory  action. 

Symptoms       The  symptoms  may  be  slight  and  not  attract  the  patient's  attention 

andPhysi-  /  J    .  \       .     ,     . 

cal  Signs,    unless  haemorrhage  or  inflammation  occurs.       I  he  physical  signs  are 

those  of  hypertrophy,  ulceration,  erosion,  lasting  for  years,  not  impli- 
cating glands,  and  not  markedly  affecting  the  patient's  health.  Large 
hypertrophies  usually  affect  the  clitoris  and  labia  majora ;  small  ones, 
the  urethral  orifice  and  hymen  (Duncan).  The  vagina  and  uterus  may 
become  affected. 

Diagnosis.  The  condition  is  rare,  but  good  drawings  are  given  by  Duncan.  It 
must  be  diagnosed  from  epithelioma  and  syphilis.  Epithelioma  is 
harder,  implicates  glands  soon,  and  has  shallow  ulcerations.  In  syphilis, 
the  history  is  the  great  test.  Jonathan  Hutchinson  alleges,  however, 
that  this  lupus  is  really  due  to  tertiary  syphilis.  There  is  good  reason 
to  believe  that  pudenda!  lupus  is  not  lupus  vulgaris,  cancer,  syphilis, 

1  Ann.  de  Gyn.,  XXVI.,  p.  1.  -  Archil- f.  Gyn.,  XXXII.,  p.  400. 


TUMOURS  OF   VULVA.  551 

nor    elephantiasis,    but    is  an   affection   sui  generis  whose   etiology  is 
unknown.     The  term  "  lupus  "  is  thus  a  clinical  one. 

The  prognosis  is  fairly  good.     Many  can  be  relieved  and  some  cured.  Prognosis. 
In   treatment,    hypertrophied   or   ulcerated   portions   are  removed   or 
cauterised  with  Paquelin's  cautery,  and  the  patient  put  on  arsenic  and 
iron. 

Kraurosis    Vulvce  or  Atrophy  of  the   Genitals.     In   old   women,  theKraurosis 
pudenda  shrink;  the  labia  minora  become  very  small;  the  vestibule Vulvae- 
atrophies  and  shrinks,  making  the  urethral  orifice  patulous  and  causing 
painful  ulceration  (v.  fig.  353). 

Microscopically,  Breisky  found  the  sebaceous  glands  of  the  labia  few, 
a  cicatricial  condition  of  the  papillae  and  thinness  of  the  rete  Malpighii. 
The  sweat  glands  were  also  diminished  in  number. 

Pudendal  hernia.     This  corresponds  with  scrotal  hernia  in  the  male.  Pudendal 
The  round  ligaments  are  the  analogues  of  the  spermatic  cord,  and  after  Hernia' 
emerging  from  the  inguinal  canal  pass  into  the  substance  of  the  labia 
majora  which  correspond  to  the  scrotum ;  if  the  process  of  peritoneum 
surrounding  the  round  ligaments — known  as  the  canal  of  Nuck — does 
not  become  obliterated  at  birth,  it  forms  a  track  for  the  hernia. 

Though  it  be  very  rare,  the  possibility  of  a  hernia  must  be  kept  in 
mind  on  examining  a  tumour  of  the  labia ;  the  crackling  feeling,  the 
impulse  communicated  on  coughing,  and  disappearance  on  taxis,  indicate 
hernia.  The  serious  consequences  of  cutting  into  such  a  hernia  by  mis- 
take for  an  abscess,  are  self-evident. 

Varix.  The  plexus  of  veins  which  forms  the  erectile  tissue  of  theVarix. 
bulbi  vaginae  has  been  already  referred  to  (v.  p.  10  and  fig.  7).  A  varicose 
condition  of  the  veins  sometimes  occurs  in  pregnancy  and  with  pelvic 
tumours.  In  a  case  described  by  Holden,1  they  formed,  when  the 
patient  was  erect,  a  tumour  of  the  size  of  a  child's  head.  When  these 
vessels  rupture  and  the  blood  is  effused  into  the  cellular  tissue,  a  hsema- 
toma  is  formed. 

Hcematoma.  This  condition  is  also  called  "  Thrombus  "  and  "  Haema-mema- 
tocele  "  of  the  vulva  ;  the  former  term  should  be  limited  to  a  coagulum 
within  a  vein,  and  the  latter  to  blood  effusion  into  the  peritoneal  cavity. 
It  arises  most  frequently  during  labour,  from  injury  produced  by  the 
child's  head ;  the  effusion  may  appear  rapidly,  as  a  tumour  from  the 
size  of  a  walnut  to  an  orange  or  larger,  or  may  take  place  gradually.  It 
has  also  been  known  to  occur  independent  of  labour  or  pregnancy,  as 
the  result  of  a  blow  or  violent  muscular  effort. 

The  treatment  consists  in  the  application  of  ice  to  the  vulva,  and 
regular  evacuation  of  the  bladder  and  rectum  without  the  patient's  being 
allowed  to  strain.  With  this  treatment,  the  mass  may  be  absorbed. 
Should  inflammation  occur,  poultices  are  applied  and  pus  is  evacuated 

i  "  Immense  Vulvar  and  Vaginal  Varix  :"  N.Y.  Med.  Record,  July  1868. 


552       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

with  the  knife ;  if  this  occurs  in  the  puerperal  condition,  special  care  is- 
required  to  keep  the  wound  aseptic  by  repeated  washing  with  carbolic 
solution  and  dressing  with  carbolised  lint. 

External  External  haemorrhage  from  ruptured  veins  sometimes  occurs.  The 
rhage.  rupture  may  be  caused  by  muscular  straining,  or  by  a  blow  or  wound  of 
the  vulva.  The  dilated  state  of  the  veins  makes  such  an  injury  serious 
during  pregnancy,  and  several  cases  of  a  fatal  result  from  a  blow  or  kick 
have  been  the  subject  of  a  criminal  prosecution  (Sir  J.  Y.  Simpson). 
The  vascular  tissues  are  forcibly  driven  against  the  pubic  arch  and  cut 
on  it.  In  a  case  recorded  by  Hyde, 1  haemorrhage  from  a  vein  ruptured 
by  a  fall  proved  fatal  in  forty  minutes.  Those  who  suffer  from  varicose 
veins  should  lie  down  for  some  hours  during  each  day ;  should  a  vein 
rupture,  the  patient  must  lie  down  at  once  and  apply  pressure  to  the 
bleeding  point. 

1  Land.  Obst.  T,-ans.,  Vol.  XI. 


CHAPTER  XLVIII. 

RUPTURE  OF  THE  PERINEUM  AND  ITS  OPERATIVE 
TREATMENT. 

LITERATURE. 

Bantock,  G.—On  the  treatment  of  Kupture  of  the  Female  Perineum,  Immediate  and 
Remote:  London,  1878.  Collis— Dub.  J.  Med.  Sc.,  May  1861.  Duncan,  John— 
Concerning  the  Closure  of  Abnormal  Anus:  Lancet,  1873,  Vol.  II.,  p.  9.  Duncan, 
Matthews— Papers  on  the  Female  Perineum :  Churchill,  London,  1879.  Emmet— 
Principles  and  Practice  of  Gynecology  :  Third  Edition  :  Philadelphia,  1884. 
Fritsch  —  Ueber  Perineoplastik :  Centr.  fur  Gynak.,  1887,  No.  30.  Goodell— 
Lessons  in  Gynecology  :  Philadelphia,  1880.  Hart,  D.  B.—  The  Structural  Anatomy 
of  the  Female  Pelvic  Floor  :  Edin.,  1880.  Heiberg—Om.  Perinaoraphi,  saerligt  med. 
Hensyn  til  Lawson  Tait's  Methode  :  Gynakalog.  og  obst.  Meddel.,  Bd.  vi.,  Hft.  3, 1887. 
Hildclrandt — Die  Krankheiten  der  ausseren  weiblichen  Genitalien  :  Stuttgart,  1877. 
Malthe — Norsk  Magazin  for  Laejevid.  enskaben,  II.  Reihe,  24  Bd.  (describes  Voss' 
Method).  Sdngcr — Ueber  Perineorraphie  durch  Spaltung  des  Septum  rectovaginale 
und  Lapeenbildung  :  Volkmann's  Sammlung,  No  301.  Schroeder — Die  Krankheiten 
der  weiblichen  Geschlechtsorgane,  S.  542 :  Leipzig,  1887.  Simpson,  Sir  J.  Y. — 
Diseases  of  Women,  p.  644.  Tait,  Lawson — A  New  Method  of  Operation  for  Repair 
of  the  Female  Perineum:  Tr.  Lend.  Obst.  Soc.,  1880.  Diseases  of  Women  and 
abdominal  Surgery,  Vol.  I.,  pp.  68-71.  Thomas— Diseases  of  Women,  p.  165  :  Phila- 
delphia, 1880.  See  Duncan  and  Hildebrandt  for  literature;  also  Index  in  Appendix. 

Preliminaries  and  Nomenclature. — The   question  as  to  the  significance  Prelimi- 
of  rupture  of  the  perineum  is  still  debated,  some  authors  believing  itna 
to  be  of  no  importance  unless  involving  the  anus  and  leading  to  incon- 
tinence of  faeces,  others  holding  that  it   is  an  important  lesion  even 
when  not  so  extensive  as  to  involve  the  bowel.     The  relation  of  rupture 
of  perineum  to  prolapsus  uteri  is  discussed  in  the   next  chapter:   at 
present  we  consider  rupture  apart  from  this.     The  'views  advanced  in 
Chapters  II.    and  IV.    must  be   kept  in  mind.       The   student  should 
glance  over  these  and  look  at  the  figures  in  Plates  I. — III. 

Complete  rupture  into  the  anus  is  serious  as  it  entails  incontinence 
of  faeces,  as  well  as  rectocele  and  some  sinking  of  the  pelvic  floor  from 
the  partial  loss  of  the  bracing-up  action  of  the  levatores  ani  (v.  p.  38). 

Another  point  to  be  kept  in  mind  is  the  anatomy  of  the  triangular 
ligament.  This  is  a  piece  of  sheet  fascia  filling  up  the  pubic  arch  and 
perforated  by  the  vagina  and  urethra.  It  strengthens  the  vaginal  walls 
by  its  grip  and,  according  to  Emmet,  prevents  their  eversion.  He 
believes  that  the  bearing  down  complained  of  by  some  women  and 
associated  with  a  lax  condition  of  the  vaginal  walls  or  the  existence 
of  rectocele  is  due  to  undue  distention  of  this  fascia  and  separation  of 
its  lateral  attachments  :  and  he  bases  on  this  a  special  operation  to  be 
described  shortly. 

It  will  be  most  convenient  to  retain  the  nomenclature  already  used 


554       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

in  the  Section  on  Anatomy.  The  pelvic  floor  is  made  up  of  pubic 
and  sacral  segments,  as  already  denned ;  in  labour,  each  of  these 
behaves  characteristically — the  pubic  segment  is  drawn  up,  the  sacral 
one  driven  down  (Chap.  IV.  and  fig.  53). 

In  this  chapter  \ve  are  specially  concerned  with  the  sacral  segment. 
During  parturition  it  is  driven  downwards  and  backwards  by  the 
advancing  foetus  and  is  more  or  less  torn  at  its  inferior  angle.  The 
term  perineum  is  often  vaguely  applied ;  in  this  Chapter,  however,  the 
perineum  is  defined  as  the  inferior  angle  of  the  sacral  segment  (v.  p.  60). 
Fig.  325  shows  the  perineum.  At  its  lower  end,  this  part  of  the 
pelvic  floor  is  made  up  of  the  following  : — 

1 .  Posterior  vaginal  wall  in  front  of  upper  part  of  perineal  body. 

2.  Hymen, 

3.  Fossa  Navicularis, 

4.  Fourchette, 

5.  Perineal  body  and  skin  over  its  base. 

These  are  mesial  structures ;  laterally,  we  have  the  labia  majora  and 
minora. 

The  perineal  body  lies  in  greater  part  below  the  level  of  the  vaginal 
entrance  and  has  as  its  functions — 

(1.)  The   union   of    the   following  muscles  —  levator   ani,    bulbo- 

cavernosus,  transversus  perinei,  sphincter  ani ; 
(2.)  The  directing  backwards  of  the  anus ; 

(3.)  The  strengthening  of  a  part  much  stretched  during  parturi- 
tion. 

PATHOLOGY    AND    VARIETIES. 

Pathology       It  should  be  kept  in  mind  that  the  vaginal  orifice  is  transverse,  the 

Varieties,   vulvar  orifice  antero-posterior. 

When  the  foetal  head  is  passing  through  the  vaginal  orifice,  it  dis- 
tends it  all  round ;  while,  when  passing  through  the  vulvar  orifice,  it 
distends  the  lower  half  of  this  only,  i.e.,  it  does  not  stretch  so  much 
those  parts  of  the  vulva  lying  above  the  level  of  the  meatus  urinarius. 

As  the  result  of  normal  and  abnormal  child-birth,  we  get  certain  tears 
of  the  inferior  end  of  the  perineum.  In  all  prirniparse  there  is 
laceration  of  at  least  the  hymeneal  orifice,  usually  mesial  and  poste- 
rior —  the  "  inevitable  laceration "  of  Matthews  Duncan.  There 
may  be  also  laceration  of  the  following  structures :  (a)  the  vaginal 
orifice,  radiating;  (6)  vestibule;  (c)  fourchette;  (d)  labia  minora;  (e) 
perineal  body  to  a  varying  depth,  the  most  extensive  involving  the 
sphincter  ani.  Further,  there  is  sometimes  central  rupture  of  the 
perineum.  In  this  lesion,  the  skin  over  the  base  of  the  perineal  bod] 
alone  may  be  involved  or  only  the  vagina  may  be  torn.  Rarely  is  it 
a  lesion  of  vaginal  wall,  connective  tissue,  and  skin,  with  an  unrupturec 


RUPTURE   OF  PERINEUM. 


555 


band  of  tissue  between  it  and  the  fourchette  (fig.  326);  this,  therefore, 
is  a  perforation  through  the  inferior  angle  of  the  thinned-out  sacral 
segment. 

ETIOLOGY. 

The  following  causes  produce  rupture  in  parturition  : —  Etiology. 

(1)  Passage  of  a  large  head  or  of  an  occipito-posterior  rotated  into 

sacrum  ;  passage  of  the  shoulders  ; 

(2)  Narrowness  of  pubic  arch; 

(3)  Straightness  of  sacrum,  as  in  flat  or  rickety  pelvis; 


FIG.  325. 

THE  SACRAL  OR  SUPPORTING  SEGMENT  OF  THE  PELVIC  FLOOR  (Hart),    e  Symphysis  pubis ; 
/  perineum  or  inferior  angle  of  sacral  segment ;  g  anus. 

(4)  Syphilitic  ulceration ; 

(5)  Rigidity  of  parts  in  elderly  primiparse ; 

(6)  Careless  use  of  forceps ; 

(7)  Too  early  passage  of  hand  into  vagina  to  bring  down  arms  in 

turning. 
Comment  on  these  would  lead  us  too  much  into  Obstetrics. 

SIGNIFICANCE    OF    RUPTURE    OF   PERINEUM. 

Rupture  of  the  perineum  involving  the  sphincter  ani  and  leading  to 
complete  or  partial  incontinence  of  fseces  is  an  important 
imperatively  demands  operation. 

Rupture  of  the  perineum  alone  and  not  involving  the  sphmcte 


556       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

may  give  rise  to  no  symptoms  unless  associated  -with  other  conditions 
causing  prolapsus  uteri.  According  to  Emmet,  the  real  accident  in 
some  cases  of  ruptured  perineum  is  tear  of  the  triangular  ligament  -where 


FIG.  320. 

CENTRAL  RUPTURE  OF  THE  PERINEUM,  the  child  was  born  not  through  the  Vulva  but  through 
the  Ruptured  Opening  (Sir  J.  Y.  Siinpson). 

it  is  perforated  by  the  vagina,  but  probably  tear  of  muscle  there  is  of 
greater  importance. 

TREATMENT. 

Treatment.      We  take  this  up  under  the  following  heads  : — 

a.  Prophylactic ; 

b.  Operative,  immediate  and  deferred. 


OPERATIVE   TREATMENT.  557 

a.  Prophylactic.  This  properly  belongs  to  midwifery.  The  obstetri-Prophy- 
cian  is  too  apt  to  think  of  the  perineum  as  something  that  delays  the1*0*10' 
exit  of  the  foetal  head,  and  to  forget  the  gynecological  aspect — that  it  is 
part  of  the  supporting  segment  of  the  pelvic  floor.  Extensive  tear  of 
this  during  labour  means  not  only  a  larger  raw  surface  for  septic 
absorption,  but  is  also  one  factor  predisposing  to  prolapsus  uteri.  The 
question,  therefore,  of  guarding  the  head  during  its  passage  over  the 
perineum  is  of  importance  but  belongs  to  obstetrics.  We  may  note 
however  that  the  foetal  head,  in  passing  through  the  outlet,  drives  the 
sacral  segment  back  and  glides  forward  in  a  direction  parallel  to  the 
driven-back  posterior  vaginal  wall.  The  normal  curve  of  the  sacrum 
favours  this  latter  motion. 

The  perineum  may  tear  (1)  from  over-distension  of  the  orifice,  or 
(2)  from  the  too  forcible  driving  of  the  foetal  head  against  it,  i.e.,  at 
right  angles  to  the  perineum ;  (3)  from  descent  of  the  sinciput  owing 
to  fixation  of  the  occiput  and  thus  substitution  of  the  larger  diameters 
of  the  head  for  the  sub-occipito  bregmatic. 

b.  Operative  treatment,  (1)  immediate  and  (2)  deferred.  No  practi- Operative, 
tioner  should  leave  a  labour  case  until  he  is  satisfied,  by  actual  inspec- 
tion or  digital  examination,  as  to  the  amount  of  perineal  tear.  When 
the  sphincter  ani  is  involved,  the  operation  is  on  no  account  to  be 
deferred  but  must  be  performed  at  the  conclusion  of  the  third  stage. 
The  practitioner  should  never  run  the  risk  of  his  patient's  having 
incontinence  of  fseces. 

(1.)  Immediate  operation.     This  belongs  to  obstetrics. 

(2.)  Deferred  operation.     This  may  be  to  operate  for  a  rupture  through  Deferred 
the  sphincter  or  to  repair  the  perineal  body.     At  present  we  consider  Oper( 
only  the  former. 

Preliminary  remarks.  In  complete  tear  through  the  anus,  the  external 
sphincter,  internal  sphincter,  and  levator  ani  are  torn.  Fig.  327  shows 
this  clearly,  and  also  explains  what  has  to  be  done.  What  is  wanted  is 
not  skin  union,  but  some  operative  measure  by  which  the  torn  muscu- 
lar ends  can  be  vivified  and  united. 

Diagnosis  of  long-standing  rupture  of  perineum  into  anus.  The  patient 
complains  of  inability  to  control  the  passage  of  flatus  or  of  faecal  matter 
when  a  call  to  stool  happens ;  she  is  especially  troubled  when  diarrhoea 
is  present.  Sometimes  there  is  a  certain  amount  of  control,  when 
some  of  the  fibres  of  the  upper  margin  of  the  internal  sphincter  are 
intact.  Patients  in  the  lower  classes  occasionally  treat  this  unpleasant 
condition  as  of  little  moment ;  to  a  woman  of  any  refinement,  the  condi- 
tion is  a  most  distressing  one. 

On  inspection,  the  practitioner  notes  that  the  skin  surface  between 
the  vaginal  and  anal  apertures  is  gone,  so  that  these  apertures  are 
blended.  The  finger  passed  into  the  rectum  feels  no  muscular  con- 


558       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

striction,  and  notes  that  the  anterior  and  posterior  rectal  walls  are  in 
contact.     The  perineal  body  appears  to  be  gone,  and  a  V-shaped  projec- 
tion of  cicatrised  mucous  membrane  (apex  above)  is  all  that  remains  of  it. 
Operation  for  restoration  of  function  of  sphincter  ani.     The  patient's 
bowels  are  first  freely  cleared  out  by  castor-oil  and  enemata  so  as  to 
ensure  that  no  scybala  remain. 
Requisites.      The  instruments  requisite  are  the  following  : — 

Angled  scissors, 

Two  pairs  of  artery  forceps, 

Plan's  forceps, 

Catgut  ligatures, 


Methods. 


FIG.  327.  FIG.  328. 

LINES  OF  INCISION  IN  OPERATION  FOB  REPAIK  OF  PASSING  OF  SUTURES  IN  SAME  OPERATION.    For 

RUPTURE  OF  PERINEUM  THROUGH  SPHINCTER  letters  see  p.  559.    The  deep  sutures  are  to 

ANI.     For  letters  see  p.  559.  be  passed  nearer  the  skin  edge. 

Silkworm  gut  or  silver  wire, 

Operating  douche, 

Fully  curved  needles,  large  and  small, 

Needle  holder. 

The  patient  is  chloroformed  and  placed  opposite  a  good  light  in  the 
lithotomy  posture.  The  knees  are  held  by  assistants  as  follows.  Each 
stands  facing  the  light,  and  places  a  knee  of  the  patient  under  the 
arm-pit  next  to  it ;  with  the  hand  of  the  same  arm,  he  exercises  ten- 
sion on  the  nates  as  the  operator  wishes.  With  his  other  hand,  the 
assistant  controls  the  patient's  foot. 

The  stages  of  the  operation  are — (1)  Forming  flaps  with  scissors,  (2) 
Applying  the  stitches. 


OPERATIVE  TREATMENT. 


559 


The  flaps,  as  made  by  A.  R.  Simpson,  are  shown  in  fig.  327.  The  A.  R. 
point  of  the  lower  blade  of  the  angled  scissors  is  entered  at  b,  pushed  Simpson's 
up  to  a,  and  then  a  clip  made  so  as  to  expose  tissue  in  line  6  a. 
The  point  is  next  entered  at  1  on  the  left  side,  and  pushed  between  the 
vaginal  and  rectal  mucous  surfaces,  i.e.,  along  the  loose  connective 
tissue  between  these  until  the  point  emerges  at  1  on  the  right  side. 
A  clip  is  then  made  so  as  to  expose  tissue  in  the  line  1  S  1.  Lastly, 
the  point  of  the  scissors  is  entered  at  b  (right  side),  and  a  b  clipped  as 
already  given  on  the  left  side.  In  this  way  an  H-shaped  figure  is  cut 
out  (fig.  3306).  These  clipped-out  lines  map  out  four  flaps  which  are 
now  to  be  raised  so  as  to  expose  for  union  the  muscular  tissue  lying 
beneath.  The  flaps  are  best  raised  as  follows  : — Lay  hold  of  flap  S  1  a 
(left)  at  angle  1,  with  P  can's  forceps,  and  raise  it  by  clipping :  do  the 


FIG.  329. 

RESULT  OF  SAME  OPERATION.    Instead  of  being  fixed  with  button-plates,  the  deep  sutures  can 
be  simply  tied  like  the  superficial  ones. 

same  with  flap  S  1  a  on  right  side.  While  the  flap  is  being  raised,  the 
index  or  middle  finger  of  the  left  hand  is  kept  on  its  vaginal  aspect  so 
as  to  regulate  its  thickness.  The  rectal  flaps  2  S  6  are  then  treated  in 
the  same  way,  the  angle  2  of  each  being  seized  with  the  forceps.  In 
this  way  a  quadrilateral  surface  is  now  laid  bare,  with  the  muscu 
ends  of  the  external  and  internal  sphincters  as  well  as  the  interlacing* 
of  the  various  muscles  of  the  perineal  body.  Fig.  330rf  will  make  this 

016*11* 

The  sutures  are  now  to  be  passed  as  follows  :-The  point  of  the  needle 
aed  with  silkworm  gut  is  entered  inside  the  skin,  carried  across,  either 


560       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 


completely  below  the  tissue  or  only  above  the  surface  at  the  apex  of 


FIG.  330a. 

EXTERNAL  GENITALS  IN  A  MULTIPARA,  WITH 
TEAR  OF  PERINEUM  SHOWING  LINE  OP 
OPERATION  (a  c  b)  FOR  LAWSON  TAIT'S 
OPERATION. 


FIG.  3306. 

DIAGRAM  SHOWING  RUPTURE  INTO  ANUS  AND 
LINE  OF  OPERATION  (/  e  g  d  c).  Anterior 
vaginal  wall  (6) ;  anus  (a) ;  g  is  on  posterior 
vaginal  wall. 


the  wound,  and  made  to  emerge  on  the  other  side  within  the  skin  sur- 


o, 


FIG.  330c. 

SHAPE  OF  RAWED  SURFACE  AFTER  FLAPS  HAVE  BEEN 
DISSECTED  UP  AND  DOWN  ;  e  and /show  relation  of 
stitches  to  skin  edge. 


FIG.  330d. 

CORONAL  SECTION  THROUGH  ANUS  (Symington), 
v  rectum ;  i  &  internal  sphincter ;  e  s  external  sphincter 
I  a  levator  ani ;  -a  vagina. 


OPERATIVE  TREATMENT.  561 

face  (fig.  330c).  The  lowest  stitches  should  pick  up  and  unite  the 
edges  of  the  external  and  internal  sphincter  (v.  fig.  G).  The  sutures 
when  tied  do  not  include  the  skin,  and  cause  no  pain  to  the  patient. 
The  vaginal  flaps  are  left  alone.  The  mucous  membrane  of  the  rectal 
flaps  may  be  sutured  with  catgut,  but  it  is  unnecessary.  Bleeding, 
which  can  be  checked  by  a  stream  of  very  hot  water  (110°-120°  F.) 
or  by  Pean's  forceps,  should  have  ceased  before  we  tie  these  sutures 
(fig.  329).  They  should  be  left  in  for  a  fortnight  and  then  removed. 
This  is  a  little  troublesome,  as  they  are  apt  to  become  buried.  The 
best  way  to  remove  them  is  to  have  the  patient  in  the  lithotomy 
posture,  to  lay  hold  of  both  ends  of  the  suture  and  pull  it  to  the  one 
side,  with  the  rake  picking  up  the  loop  (fig.  391). 

The  advantages  of  this  method  of  operating  are  very  great.  It  can 
be  done  very  rapidly,  ensures  muscular  union,  does  not  allow  skin  or 
mucous  membrane  to  interfere  with  the  union  of  muscle,  and  is  a  great 
improvement  on  the  old  methods.  In  these  the  union  often  seemed 
sound,  but  the  patient  had  no  additional  control  from  want  of  muscular 
union. 

This  method  is  not,  strictly  speaking,  that  of  one  operator,  but  has 
been  evolved  as  follows  : — In  1872  John  Duncan  closed  an  artificial 
anus  following  gangrenous  femoral  hernia  by  dissecting  up  the  mucous 
membrane  round  the  orifice  for  more  than  half  an  inch,  invaginating 
this  dissected  portion  and  bringing  the  raw  surfaces  together  with 
interrupted  catgut  sutures  :  the  margins  of  the  skin  were  then  pared 
and  brought  together  by  wire. 

Collis,  of  Dublin,  in  1861,  in  a  case  of  vesico  -  vaginal  fistula 
split  the  edges  of  the  fistula  instead  of  paring  them.  A.  Russell 
Simpson  applied  the  separation  of  the  mucous  membrane  introduced 
by  Duncan,  to  tear  of  the  perineum  involving  the  anus,  splitting  the 
septum  between  anus  and  vagina  and  sewing  similar  mucous  membranes 
to  each  other  as  well  as  bringing  the  deep  raw  surfaces  into  union.  This 
procedure  really  forms  vaginal  and  rectal  flaps.  Lawson  Tait  improved 
on  this  by  the  use  of  angled  scissors,  and  also  introduced  the  method  of 
passing  the  sutures  inside  of  the  skin  instead  of  through  it  as  formerly 
done. 

The  use  of  scissors  to  form  flaps  is  also  applicable  in  perineum  opera- 
tions where  the  anus  is  not  torn.  According  to  Sanger,  Stein,  a  Danish 
surgeon,  and  Voss,  a  Norwegian,  have  employed  somewhat  similar 
methods  in  complete  rupture. 

The  continuous  spiral  catgut  suture  is  now  much  used  in  Germany 
in  such  cases  and  has  many  advantages.  It  is  very  quickly  passed, 
brings  the  surfaces  well  into  apposition  and  does  not  require  to  be 
removed.  The  catgut  used  must  be  specially  prepared  with  oil  of 
juniper  and  corrosive  sublimate  so  as  to  be  aseptic  and  last  8  or  9  days. 
2  N 


562       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

In  this  operation  it  is  to  be  used  as  follows.  With  a  curved  rounded 
needle  begin  at  the  apex  of  the  rectal  surfaces  and  knot  the  first  stitch 
securely.  Then  pass  the  suture  continuously  to  the  lower  end  of  the 
rectal  stitches,  up  the  intermediate  portions,  and  finally  unite  the  vaginal 
flaps  and  any  skin  portion  un-untied.  The  last  stitch  is  securely  knotted 
of  course. 

After-treatment.  The  patient's  food  must  be  liquid  and  not  too  abun- 
dant. The  bowels  are  to  be  confined  for  3  days  and  then  moved  by  a 
small  dose  of  castor-oil  every  second  day.  Prior  to  the  motion,  the 
nurse  must  inject  a  large  amount  of  oil  and  see  that  scybala  if  present  are 
broken  down.  Unless  the  nurse  is  skilled,  the  operator  or  his  assistant 
must  attend  to  this.  The  stitches  are  removed  on  the  14th  to  21st  day. 


FIG.  331. 

EMMET'S  OPERATION  FOR  RUPTURED  PERINEUM  (Dudley).1 

Operation  for  Rupture  of  the  Perineum,  the  Sphincter  ani  not  being 
involved.  This  is  described  in  chapter  on  Prolapsus  uteri. 

Emmet  has  devised  an  operation  with  the  view  of  restoring  the  grip 
of  the  fascia,  forming  the  triangular  ligament,  upon  the  vaginal  wall. 
A  double  triangular  raw  surface  is  made  on  the  posterior  vaginal  walls. 
One  of  these  is  seen  at  a  b  c  (fig.  331)  stretched  by  three  tenacula.  The 
sutures  are  now  passed  along  the  upper  margin  in  loops  so  as  to  fold 
this  edge  a  b  on  itself  at  its  central  point  d,  which  is  hooked  up  in  a 
fourth  tenaculum.  The  third  figure  shows  this  done  on  both  sides  and 
these  sutures  tied.  Finally,  additional  sutures  are  passed  through  the 
edge  b  c  so  as  to  unite  it  with  the  corresponding  part  of  the  other 
triangular  raw  surface. 

1  Pepper's  System  of  Medicine,  Vol.  IV.,  pp.  164,  165.— London  :  Sampson  Low,  Marston,  Searle, 

and  Rivington,  1886. 


CHAPTER  XLIX. 

DISPLACEMENTS   OP   PELVIC   FLOOR:   PROLAPSUS 
UTERI;   VAGINAL   ENTEROCELE. 

LITERATURE. 

Alexander— The  Treatment  of  Backward  Displacements  of  the  Uterus  and  of  Pro- 
lapsus Uteri  by  the  New  Method  of  Shortening  the  Round  Ligaments:  London, 
Churchill,  1884.  Duncan,  Matthews— Papers  on  the  Female  Perineum  :  Churchill, 
London,  1879.  Emmet  —  Principles  and  Practice  of  Gynecology,  p.  367 :  Lond. 
1879.  Freund,  W.  A. — Ueber  die  Figur  des  normalen  Lumen  vaginse  und  tiber 
Dammplastik  mit  Demonstrationen  :  Arch.  f.  Gyn.,  Bd.  VI.,  p.  317.  Fritsch — 
Die  Lageveriinderungen  der  Gebarmutter,  Billroth's  Handbuch :  Stuttgart,  1879. 
Qoodell— Lessons  in  Gynecology,  Lesson  VII.  :  Philadelphia,  1879.  Hart— The 
Structural  Anatomy  of  the  Female  Pelvic  Floor :  Edinburgh,  1880.  Hegar  und 
Kalteribach — Operative  Gynakologie,  1881.  Huguier — Memoir  sur  les  Allongements 
Hypertrophiques  du  Col  de  1'Uterus :  Paris,  1860.  Legendre — De  la  chute  de 
1'Uterus.  Martin — Ueber  den  Scheiden  und  Gebarmuttervorfall :  Volk.  Samml., 
Nos.  183,  184.  Schatz — Ueber  die  Zerreissungen  des  Muskulosen  Beckenbodens  bei 
der  Geburt:  Archiv  f.  Gyn.,  XXII.,  S.  298.  Scfiroeder— Die  Krankheiten  der 
weiblichen  Geschlechtsorgane  :  Leipzig,  1879.  Schultze — Die  Pathologic  und 
Therapie  der  Lageveranderungen  der  Gebarmutter  :  Berlin,  1881.  Schiitz — Median- 
schnitt  (lurch  das  Becken  einer  Frau  mit  Scheiden  und  Uterus  Vorfall :  Arch.  f. 
Gyn.,  Bd.  XIII.,  S.  262.  Sims,  Marion — Uterine  Surgery :  London,  1865.  Skenc 
— Injuries  to  the  Pelvic  Floor  from  Partxirition  and  Other  Causes :  N.  Y.  Med.  Jour., 
Vol.  XLL,  1885.  Spiegelbcrg — Ein  anderer  Medianschnitt  durch  ein  Becken  mit 
Scheiden  Gebarmutter-Vorfall :  Archiv  f.  Gyn.,  Bd.  XIII.,  S.  271.  Thomas— 
Diseases  of  Women,  p.  168 :  Philadelphia,  1880.  Veit — Klinische  Untersuchungen 
iiber  den  Vorfall  der  Scheide  und  der  Gebarmutter:  Zeits.  f.  Geb.  u.  Gyn.,  Bd.  I. 
Winckel — Die  Pathologic  der  weiblicheu  Sexualorgane :  Leipzig,  1880.  See  also 
Index  of  Recent  Gynecological  Literature  in  the  Appendix. 

Preliminary    Considerations.      The    subject   of  this   chapter   can   only  Prelimi- 
be  understood  in  the  light   of  an  accurate  knowledge  of  the  normal na 
structural   anatomy   of  the   pelvic   floor,   and  a  consideration   of  the 
changes  it  undergoes  during  parturition,  and  in  the  displacements  to  be 
considered.     Our  information  on  the  last  point  leaves,  however,  much 
to  be  desired.     The  student  should  read  over  Chap.  IV. 

We  note  here  that  the  pelvic  floor  is  to  be  considered  as  made  up  of 
the  two  portions  termed  the  "  entire  displaceable  "  and  "  entire  fixed." 

Fig.  325  shows  a  sagittal  mesial  section  of  the  pelvis  with  the  "entire 
displaceable  portion"  removed  and  the  entire  fixed  portion  left:  PI.  II., 
fig.  2,  shows  the  two  portions  in  axial  coronal  section. 

These  two  portions  are  separated  by  loose  connective  tissue.     During 


564       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

parturition  the  child  is  driven  through  the  vagina,  i.e.,  through  the 
pelvic  floor,  which  becomes  canalized  or  opened  up  through  this  process. 
If  we  regard  this  process  only  in  sagittal  mesial  section  as  shown  in 
Braune's  plate,  we  see  that  the  pubic  segment  is  drawn  up  and  the 
sacral  one  driven  down  and  back  and  the  vagina  in  addition  greatly 
distended.  If  considered  in  axial  coronal  section  we  should  see  the 
"  entire  displaceable  portion "  in  part  drawn  up,  the  foetus  driven 
through  it  and  thus  the  levatores  ani  and  glutei  muscles  in  the  "  entire 
fixed  portion  "  driven  out  and  back  and  the  former  perhaps  torn  (Schatz) 
or  at  any  rate  elongated,  and  their  slope  diminished.  The  slit  in  the 
triangular  ligament  through  which  the  vagina  passes  is  also  dilated,  and 
may  be  unduly  so.  The  upward  traction  exercised  on  the  "  entire  dis- 
placeable portion  "  necessarily  elongates  or  slackens  the  loose  connective 
tissue  joining  the  two  portions  and  is  one  factor  in  bringing  about 
prolapsus  uteri.  As  the  result  therefore  of  the  structure  of  the  pelvic 
floor,  of  lesions  caused  by  parturition,  and  intra-abdominal  pressure,  we 
may  get  certain  conditions,  viz., 

I.  Undue  yielding  or  bulge  of  the  pelvic  floor ; 

II.  Prolapse  of  the  "  entire  displaceable  portion  "  with  the  uterus  and 

abdominal  viscera,  in  part,  past  the  "  entire  fixed  portion  "- 
so-called  prolapsus  uteri : 

III.  Vaginal  enterocele, — anterior  and  posterior. 

1.  Undue  yielding  or  bulge  of  the  whole  pelvic  floor.  This  is  a  con- 
dition to  which  attention  has  been  drawn  by  Herman  and  Skene.  Our 
knowledge  on  this  lesion  is  however  very  defective  and  calls  for  investi- 
gation. In  Chap.  IV.  attention  has  been  called  to  the  normal  pelvic- 
floor  projection.  In  undue  bulging  of  the  pelvic  floor  this  is  increased. 
Herman  measures  with  a  tape  the  length  of  the  arc  described  by  the 
curved  skin  aspect  of  the  pelvic  floor  between  tip  of  coccyx  and  lower 
margin  of  symphysis  pubis.  This  average,  about  four  inches,  may  be 
increased  by  straining,  in  virgin  cases,  to  four  and  a  half  inches ;  but  in 
cases  of  undue  bulge,  to  about  six  or  more. 

Causation.  This  lesion  is  due  to  parturition ;  we  are  not  yet  in  a 
position  to  give  precise  details,  owing  to  the  complete  want  of  sectional 
and  dissectional  work  on  the  pelves  of  women  with  such  a  prolapsed  con- 
dition. Schatz  and  Skene  have  described  certain  conditions  of  lacera- 
tion of  the  levator  ani  muscles,  atrophy  and  permanent  paralysis,  but 
all  has  been  based  on  clinical  investigation  uncorrected  by  anatomical 
examination.  The  subject  however  is  important,  the  researches  so  far 
suggestive,  and  further  accurate  work  called  for. 

The  symptoms  of  undue  yielding  are  bearing  down  pain  with  draggings 
in  loins  and  hips. 

The  treatment  is  the  use  of  an  abdominal  belt  with  a  perineal  band. 


PROLAPSUS   UTERI.  565 

II.    PROLAPSUS  UTERI. 

DEFINITION. 

A  downward  displacement  of  entire  displaceable  portion  of  pelvic 
floor,  uterus  and  appendages,  past  entire  fixed  portion ;  with  coincident 
descent  of  small  intestine. 

PRELIMINARIES. 

The  subject  of  Prolapsus  Uteri  is  a  complex  one,  and  has  been  in 
part  made  so  by  erroneous  terminology. 

Thus  the  well-known  term  Prolapsus  Uteri  has  biassed  many  observers 
as  to  the  nature  of  this  lesion,  inasmuch  as  they  have  considered  some 
change  in  the  uterus  as  initiating  the  prolapsus.  This  is  a  natural  error, 
and  is  perpetuated  in  most  of  our  text-books  by  the  writers  of  these 
considering  prolapsus  uteri  under  affections  of  the  uterus.  Prolapsus 
uteri  is,  however,  considered  here  under  Displacements  of  the  Pelvic 
Floor,  as  it  is  really  a  hernial  displacement  of  part  of  the  pelvic  floor 
in  which  the  entire  displaceable  segment  of  the  pelvic  floor,  uterus,  and 
appendages  are  driven  down  by  intra-abdominal  pressure.  There  is  no 
doubt  that  change  takes  place  in  the  length  of  the  uterus  as  the  result 
of  the  downward  displacement.  This  change  is,  however,  a  secondary 
one,  as  will  presently  be  explained,  and  does  not  initiate  the  lesion. 

The  student  must  therefore  use  the  term  prolapsus  uteri  not  in  its 
literal  sense,  but  as  equivalent  to  "  sacro-pubic  hernia." 

Prolapsus  uteri  is  sometimes  applied  to  hypertrophy  of  the  vaginal 
portion  of  the  cervix.  This  is  wrong,  as  this  hypertrophy  is  a  growth 
phenomenon. 

ETIOLOGY. 

The  factors  producing  prolapsus  uteri  are  three  in  number: — (1) 
Deficient  support  by  entire  fixed  portion ;  (2)  Deficient  tone  of  entire  dis- 
placeable segment  of  pelvic  floor,  and  slackening  of  loose  tissue  round  it  ; 
(3)  Intra-abdominal  pressure. 

Deficient  support  by  entire  fixed  portion.  By  this  is  meant  that  through 
parturition  the  sacral  segment  has  become  straightened  out  or  deficient 
at  its  lower  margin— the  perineum — and  that  the  slope  of  the  levatores 
ani  has  been  lessened  or  that  they  have  been  torn  (Schatz).  It  is 
wrong  to  imagine  that  tear  of  the  perineum  is  everything  in  prolapsus 
uteri ;  the  perineum  may  be  considerably  torn  and  yet,  if  the  sacral 
segment  is  still  sufficiently  curved  and  the  intra-abdominal  pressure  not 
too  great,  there  will  be  no  prolapsus.  Tear  of  the  perineum  diminishes 
the  sacral  support,  and  deficient  sacral  and  levator-ani  support  makes 
the  task  of  intra-abdominal  pressure  easier. 


566       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

The  bearing  of  the  second  and  third  factors  is  sufficiently  evident. 
Of  all  the  three,  increased  intra-abdominal  pressure  is  the  most 
important  and  is  sufficient  to  cause  prolapsus  in  virgins.  The  first  and 
second  are  adjuvant. 

NATURE. 

The  uterus  has  nothing  to  do  with  prolapsus.  It  is  a  classical  term, 
but  a  misleading  one.  Prolapsus  uteri  is  really  a  hernia  ;  and  is  analo- 
gous in  every  point  to  what  we  term  a  surgical  hernia  (such  as 
inguinal  hernia). 

Thus  it  has  (1)  a  sac,  the  peritoneum ;  (2)  a  definite  road  to  travel 


FIG.  332. 

To  SHOW  THE  HERNIAL  NATURE  OF  PROLAPSUS  UTERI  ;  o.  peritoneum ;  b  bladder ;  c  uterus ; 
d  anterior  vaginal  wall ;  e  anterior  rectal  wall ;  /  perineum  ;  y  posterior  vaginal  wall.  The 
dark  portions  are  the  coverings  of  the  Hernia  (after  Schiitz). 

along,  whose  boundaries  are — a.  in  front,  the  symphysis  pubis,  b.  behind, 
the  portion  of  the  sacral  segment  of  the  pelvic  floor  from  anterior  wall 
of  rectum  back  to  sacrum,  c.  side  walls,  viz.,  obturator  internus  and 
levator  ani  muscles ;  (3)  definite  coverings,  viz.,  a.  pubic  segment  of 
pelvic  floor,  b.  the  uterus,  c.  posterior  vaginal  wall.  Like  all  hernise,  its 
sac  contains  small  intestine,  (fig.  332) 

Huguier  alleged,  wrongly  we  believe,  that,  by  a  hypertrophic  elongation 
of  the  supra-vaginal  portion  of  the  cervix,  the  bladder  and  posterior 


PROLAPSUS    UTERI.  567 

vaginal  wall  were  displaced  downwards  ;  and  that  many  cases  of  alleged 
prolapsus  uteri  are  really  due  to  this.  Such  cases  differed  from 
prolapsus  uteri  in  the  fact  that  the  fundus  uteri  and  fundus  of  bladder 
are  in  position.  Many  gynecologists  hold  this  view  of  Huguier,  most  of 
them  modifying  it  somewhat.  Schroeder's  Handbook,  Goodell's 
Gynecology,  and  Hart's  Structural  Anatomy  may  be  consulted  on  this 
moot  point. 

SYMPTOMS    AND    PHYSICAL    SIGNS. 

The  discomfort  caused  by  the  protrusion  and  the  excoriation  of  the 
parts  is  the  prominent  symptom.  The  patient  complains  of  "  something 
coming  down  in  front."  Further,  there  is  difficulty  in  micturition. 

The  physical  signs  are  distinct.  If  the  prolapsus  be  incomplete,  a 
portion  of  the  anterior  vaginal  wall  has  passed  out  at  the  vaginal  orifice, 
the  os  uteri  is  equally  displaced  downwards,  and  the  posterior  fornix  is 
apparently  deeper  from  the  descent  of  the  cervix.  The  uterus,  in 
addition  to  being  low  down,  is  usually  enlarged ;  it  lies  with  its  axis 
coinciding  with  that  part  of  the  pelvic  curve  in  which  it  is.  If  the 
prolapsus  be  complete,  we  find  the  whole  anterior  vaginal  wall  outside 
the  vulva,  the  cervix  extruded,  and  the  posterior  vaginal  wall  everted 
(fig.  176).  The  student  must  specially  note  that  this  description  is 
based  on  clinical  observation. 

From  the  study  of  frozen  sections,  we  further  learn  that  the  posterior 
vaginal  and  anterior  rectal  walls  are  separated  by  peritoneum  driven  in 
between  them,  and  that  the  uterus  with  other  parts  has  become 
hypertrophied  through  long-standing  congestion,  and  the  cervix 
elongated. 

MECHANISM    OF    PROLAPSUS. 

The  displaced  organs  can  be  replaced— posterior  vaginal  wall  first, 
then  uterus,  and  lastly  pubic  segment ;  on  the  patient's  straining,  the 
mechanism  of  the  displacement  is  repeated,  is  seen  to  be  perfectly 
definite  and  to  occur  as  follows. 

We   have  first  the  appearance  of  the   anterior   vaginal  wall, 
below  upwards,  at  the  orifice.     Pari  passu  with  its  descent,  the  uterus  qbserva- 
and  posterior  vaginal  wall  have  come  down;  the  cervix  tracing  out  thetions. 
pelvic  curve,  while  the  uterus  becomes  more  and  more  inclined  back- 
wards until  at  the  vaginal  orifice  it  lies  in  the  vaginal  axis ;  the  posterior 
vaginal  wall  forms  a  pouch,  the  depth  of  half  its  own  length,  behind  it. 
Finally  the  uterus  is  driven  outside ;  the  cervix  sweeps  upwards 
forwards,  and  the  posterior  vaginal  wall  is  now  completely  everte 
its  lowest  part  appearing  last.  Appear- 

On   vertical   section,  we   now   find   these   conditions :— (1)    Ala  stprolftp8?g 
complete  extrusion  of  the  anterior  or  pubic  part  of  the  floor,  the  upper  on  S< 


568       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

and  anterior  part  of  the  bladder  still  behind  the  symphysis ;  (2)  Com- 
plete extrusion  of  the  uterus,  which  sometimes  lies  with  the  fundus 
below  the  level  of  the  anus ;  (3)  Rectum  in  position  and  only  posterior 
vaginal  wall  down  ;  the  latter  has  peeled  from  the  rectum  downwards 
as  far  as  the  lowest  inch-and-a-half  (of  close  connection)  which  is 
elongated  (fig.  332). 

The  explanation  of  this  mechanism  is  as  follows.  The  displacement  in 
prolapsus  uteri  is  caused  by  intra-abdominal  pressure,  pushing  down 
that  part  of  the  pelvic  floor  which  lies  in  front  of  the  anterior  rectal 
wall,  and  inside  the  obturator  internus  and  upper  portion  of  the  levator 
ani  muscles.  This  part  consists  of  entire  displaceable  portion  of  pelvic 
floor,  with  uterus  and  appendages.  If  we  now  look  at  a  section  of  the 
pelvis  such  as  is  seen  in  PI.  I.  (vertical  mesial  section)  we  find  the 
posterior  angle  of  the  pubic  segment  is  attached  to  the  cervix  uteri,  and 
the  cervix  uteri  to  the  top  of  the  posterior  vaginal  wall.  Thus,  if 
intra-abdominal  pressure  is  excessive,  this  part  when  driven  down  must 
have  the  following  sequence  of  protrusion  at  the  vaginal  orifice : 
(a)  Anterior  vaginal  wall  from  below  up  ;  (6)  Cervix  uteri ;  (c)  Posterior 
vaginal  wall  from  above  downwards. 

Our  knowledge  of  the  side  relations  in  prolapsus  is  not  yet  known, 
but  from  the  structure  of  the  normal  pelvis,  we  believe  that  separation 
takes  place  inside  the  obturator  internus  and  upper  portion  of  the 
levator  ani  muscles  (v.  Chap.  IV.). 

The  iiterus,  while  it  is  being  forced  down,  has  the  direction  of  its  long 
axis  continually  altering.  This  is  often  expressed  by  saying  that  the 
uterus  becomes  more  and  more  retroverted,  as  it  is  forced  down.  The 
real  fact  is,  that,  as  the  pubic  segment  is  forced  down,  it  is  stretched — 
chiefly  on  its  peritoneal  aspect.  In  this  way  tension  is  made  on  the 
cervix  uteri,  with  the  effect  of  throwing  the  fundus  back  and  making  it 
rest  on  the  retrojacent  structures.  As  these  have  (roughly  speaking) 
the  pelvic  curve,  we  get  the  uterus  in  this  way  constantly  altering  the 
lie  of  its  axis. 

The  enlargement  is  not  purely  cervical ;  but  affects  the  whole  uterus, 
the  pubic  segment,  and  the  posterior  vaginal  wall.  This  enlargement  is 
a  consequence  of  prolapsus  uteri,  and  not  a  factor  in  its  production.  If 
we  view  a  prolapsed  uterus  (with  the  os  at  the  ostium  vaginse)  through 
the  pelvic  brim,  it  can  be  seen  that  it  lies,  as  it  were,  at  the  bottom  of 
a  valley — the  sides  of  the  valley  being  the  broad  ligaments,  the  bed  of 
the  valley  the  uterus.  The  parts  of  the  uterus  do  not  lie  on  the  same 
horizontal  plane,  the  cervix  lies  low.  It  is  thus  probable  that  the 
venous  supply  of  the  uterus,  having  a  mechanical  disadvantage  to  its 
return,  may  have  a  tendency  to  stasis.  This  may  lead  to  areolar 
hyperplasia  at  first,  and,  so  far  as  our  present  knowledge  goes,  partly 
accounts  for  the  increased  size  of  the  uterus  in  prolapsus.  There  is 


PROLAPSUS   UTERI.  569 

further  probably  a  tensile  elongation  of  the  cervix  produced  which 
increases  the  uterine  length. 

SUMMARY    OP   DISPLACEMENT   IN   PROLAPSUS. 

I.  On  clinical  observation  while  a  complete  prolapsus  is  being  repro- 
duced, we  note — 

(a)  The  anterior  vaginal  wall  from  below  upwards  passing  down 

and  out  at  the  vaginal  orifice  ; 

(6)  The  cervix  uteri  appearing  at  the  vaginal  orifice  ; 
(c)   The    posterior    vaginal    wall,    from    above    down,   coming 

last. 

II.  If  a  frozen  section  of  a  cadaver  with  prolapsus  uteri  be  examined 
(fig.  332),  we  note  that  the  pubic  segment,  uterus  and  posterior  vaginal 
wall  are  displaced  down  and  out.     Fig.  332  is  based  on  Schutz's  draw- 
ing of  such  a  frozen  section.     Axial  coronal  sections  have  not  as  yet 
been  published,  but  the  ureters  are  displaced  down  along  with  the 
bladder,  and  by  being  pressed  on  by  the  pubic  arch  may  give  rise  to 
uraemia,  as  in  a  case  recorded  by  A.  E.  Barker  of  University  College, 
London. 

III.  The  combined  study  of  I.  and  II.  shows  that 

The  bladder  and  uterus  are  displaced  down,  the  vagina 
everted  or  turned  inside  out,  the  small  intestine  coin- 
cidently  lowered  in  the  pelvis,  the  displaced  parts  con- 
gested and  hypertrophied,  and  the  cervix  uteri  elongated 
secondarily. 

DIAGNOSIS   AND    DIFFERENTIAL   DIAGNOSIS. 

The  diagnosis  is  made  by  noticing  the  relation  of  the  parts  ex- 
truded and  by  passing  the  sound  if  necessary  into  the  bladder  and 
uterus. 

The  differential  diagnosis  must  be  made  from  the  following  condi- 
tions : — 

(1.)  Hypertrophy  of  the  vaginal  portion  of  the  cervix; 
(2.)  Hypertrophy  of  the  supra-vaginal  portion  of  cervix. 

For  both  of  these  conditions  the  student  is  referred  back  to  page  279 
(see  figs.  166,  174,  175). 

(3.)  Cystocele.  Uterus  is  in  position,  and  displacement  is  found 
to  be  due  to  bulging  back  of  posterior  wall  of  bladder. 

(4.)  Rectocele.  The  finger,  passed  through  the  anus,  can  be 
pushed  into  the  pouched  rectum. 

(5.)  Inversion  and  polypus  (v.  p.  392). 


570       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 


TREATMENT. 

A.  Treatment  by  pessaries, 

B.  Treatment  by  operation. 

A.  Treatment  by  pessaries.  In  slight  cases,  where  the  anterior  vaginal 
wall  protrudes  only  a  little,  we  may  use  an  Albert  Smith  or  Hodge 
pessary,  with  or  without  transverse  bars  at  the  lower  part.  If  this  fails, 


FIG.  333. 

GREENHALGH'S  PESSARY,  with  transverse  bars. 


FIG.  334. 
RING  PESSARY,  with  diaphragm. 


a  ring  pessary  with  spring  inside  should  be  tried ;  this  instrument  is 
useful  here,  inasmuch  as  it  is  shorter  vertically  than  the  Albert  Smith 
and  therefore  does  not  project  over  the  lower  end  of  the  shortened  pos- 
terior vaginal  wall.  The  instrument  may  be  made  of  vulcanite,  block 
tin,  or  india-rubber.  The  india-rubber  forms  are  best,  and  may  be 
provided  with  a  perforated  diaphragm,  but  this  tends  to  retain  dis- 
charge. 

The  pessary  is  taken  in  the  right  hand,  and  compressed  between  the 


FIG.  335. 

SIMPLE  ELASTIC  RINO  PESSARY,  compressed  between  the  fingers  for  introduction  (De  Sinety). 

finger  and  thumb  as  in  fig.  335  while  it  is  being  passed  through  the 
vaginal  orifice  ;  the  labia  are  separated  with  the  fingers  of  the  left 
hand. 

If  the  ring  instrument  fail,  then  others  may  be  tried.  Fig.  337  shows 
Zwanck's  pessary,  a  bad  form.  A  thin  india-rubber  bag  distended  with 
air  and  provided  with  a  stop-cock  is  good.  In  very  bad  cases  and  in  old 
women  where  an  operation  is  out  of  the  question,  the  patient  or  her 


PROLAPSUS   UTERI.  571 

friends  should  be  instructed  how  to  pack  the  vagina  with  marine  lint ; 


FIG.  336. 

RING  PESSARY  tit  situ  (Hart). 


the  packing,  if  thorough,  may  remain  in  situ  for  a  week.     Some  recom- 


FIG.  337. 

ZWANCK'S  PESSARY  FOR  PROLAPSUS. 


mend  pessaries  which  are  attached  externally  to  an  abdominal  belt 


572       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

When  there  is  much  congestion  and  excoriation,  rest  in  bed  with  the 
use  of  alum  injections  (3i  to  Oi)  and  application  of  boracic  or  zinc  oint- 
ments to  the  raw  surfaces,  are  indicated. 

If  the  patient  has  good  abdominal  development,  an  abdominal  belt 
will  be  of  use  ;  when  applied,  it  should  be  fairly  tight  at  the  lower  edge 
and  slack  at  the  upper  one. 

B.  Treatment  by  operation.     We  must  first  consider  the  status  quo  in 


FIG.  338. 

LINES  OF  INCISION  IN  OPERATION  TOR  REPAIR  OF 
RUPTURED  PERINEUM.    For  letters  see  text. 


FIG.  339. 

SUTURES  PASSED  IN  SAME  OPERATION. 


an  advanced  prolapsus. 
lesions  :  — 


There  are  the  following  primary  and  secondary 


Condition 
of  Parts  in 
Prolapsus 

Uteri. 


Primary 


(1)  Perineal  body  usually  torn  and  perineal  union  of 

levatores  ani,  transversi  perinei,  and  bulbo-caver- 
nosi,  torn  to  a  greater  or  less  extent ; 

(2)  Increase  of  intra-abdominal  pressure  ; 

'(3)  Congestion  with  areolar  hyperplasia  of  uterus,  pubic 
segment,  and  posterior  vaginal  wall ;  laxity  of 
everted  vagina ; 

(4)  Separation  of  anterior  rectal  and  posterior  vaginal 
walls  and  of  vagina  and  bladder  from  their 
lateral  relations,  with  peritoneum  clothing  the 
separated  surfaces. 

These  secondary  lesions,  especially  the  last,  are  serious  and  incurable. 


Secondary 


PROLAPSUS   UTERI. 


573 


In  order  to  restore  the  pelvic  floor  to  its  pristine  state  we  should  require 
(1)  to  repair  the  perineal  body  and  narrow  the  vagina ;  (2)  to  restrain 
increased  abdominal  pressure  ;  these  are  possible  :  (3)  to  do  away  with 
congestion  and  areolar  hyperplasia  is  probably  beyond  our  powers,  while 
(4)  to  bring  about  adhesion  of  the  anterior  rectal  and  posterior  vaginal 
walls  and  to  restore  the  lateral  supports  is  impossible.  Prolapsus  uteri 
is  therefore  a  condition  with  serious  and  irremediable  secondary  results. 

OPERATIVE  TREATMENT  OF  PROLAPSUS  UTERI. 

For  operative  purposes  we  consider  prolapsus  uteri  as  a  downward 


FIG.  340. 

NEEDLE  CARRYING  IN  STITCHES  FOR  REPAIR  OK  THE  PERINEUM  (Sir  J.  T.  Simpton). 

and  outward  displacement  of  the  entire  displaceable  portion  of  the  pelvic 
floor  past  the  entire  fixed  portion,  with  eversion  of  the  vaginal  walls. 
The  various  operations  may  be  classified  as  follows  :— 
1    Those  that  aim  at  giving  a  support  to  the  prolapsed  portions  by 
repairing  the  lower  edges  of  the  sacral  segment  (Perineorraphy)  and 
the  lower  uniting  edges  of  the  labia  majora  (Episioperineorraphy) ; 
2.  Those  that  aim  at  causing  a  narrowing  of  the  vagina    wal 
bringing  about  their  partial  union  so  that  they  are  less  e 
(Elytrorraphy) ; 


574       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

3.  Those  that  combine  1  and  2 ; 

4.  The  special  operation   which  draws  up   the   entire   displaceable 
portion  by  shortening  the  round  ligaments  of  the  uterus  (Alexander- 
Adams  Operation). 

Preliminary  Considerations  as  to  Operative  Technique.  It  should  be 
noted  here  that  the  method  of  rawing  the  surfaces  has  recently  under- 
gone a  change.  Formerly  it  was  done  with  knife  and  forceps  and  the 
tissue  removed :  now  scissors  are  often  employed  so  as  to  raise  flaps 
thus  exposing  a  raw  surface  for  union  without  loss  of  tissue. 

1.  Those  that  aim  at  giving  a  support  to  the  prolapsed  portions  by 
Operations  repa{riny  t/ie  lower  edges  of  the  sacral  segment  and  uniting  the  loiver 
lapsus.  portions  of  the  labia  majora. 


FIG.  341. 
EESULT  OF  SAMK  OPERATION. 


(1)  Perineorraphy.  This  operation  aims  at  restoring  the  perineal 
body,  i.e.,  it  freshens  and  unites  the  torn  surfaces.  Perineorraphy  alone 
is  only  of  use  as  an  operation  in  slight  cases,  inasmuch  as  the  part 
restored  lies  mainly  beyond  the  vaginal  walls  and  therefore  in  no  way 
hinders  their  eversion,  although  it  may  make  the  vulvar  opening  through 
which  they  pass  somewhat  narrower.  We  describe  this  operation  briefly 
as  it  is  always  combined  with  union  of  the  lower  portions  of  the  labia 
majora  (Episioperineorraphy)  or  some  operation  causing  cicatrization  of 
the  posterior  vaginal  walls  (Elytroperineorraphy). 

In  the  operation  we  chloroform  patient,  use  douche  and  have  knees 
held  as  described  at  page  559  ;  make  incision  b  c  and  a  b  ans  in  fig.  338; 


PROLAPSUS   UTERI.  575 

dissect  up  flaps  and  pass  stitches  as  in  figs.  339,  340  341  After  treat 
ment  and  removal  of  stitches  as  at  page  561.  As  already  said  this 
operation  by  itself  is  not  of  the  remotest  use  unless  it  gets  union  of  torn 
muscles,  but  it  allows  a  pessary  to  be  retained. 

(2)  Episioperineorraphy.       In   this   operation   the  lower  portions  of 
the  labia  majora,  as  well  as  the  cicatrized  surfaces  of  perineal  body 
arc  vivified  and  the  opposing  raw  surfaces  united  with  silkworm  gut 
sutures. 

Lawson  Tait  operates  with  angled  scissors  as  follows.  He  first 
notches  the  cicatrized  surface  mesially  at  the  anterior  portion  of  the 
perineum,  the  scissors  being  held  parallel  to  the  long  axis  of  the 


FIG.  342. 

TO  SHOW  VARIOUS  FORMS  OF  RAW  SURFACE  MADE  ON  POSTERIOR  VAGINAL  WALL  IN  OPERATION  FOR 
PROLAPSUS  UTERI:  1111,  Hegar's;  2222,  BischoflTs ;  3333,  Simon's;  444oA  Winckel's.  (Winektl) 

patient's  body.  One  blade  is  entered  at  right  angles  to  this  and 
pushed  up  in  one  labium  majus  to  the  base  of  the  labium  minus  or 
beyond.  The  same  is  done  on  the  opposite  side.  Thus  a  U-shaped 
incision  is  made.  Silkworm  catgut  stitches  are  passed  to  unite 
each  side  as  follows.  A  handled  needle  is  used  and  the  point  entered 
inside  the  skin,  say  on  the  left  side  and  out  inside  the  mucous  mem- 
brane of  the  same  side.  The  needle  is  then  withdrawn,  and  passed  at  a 
corresponding  part  on  the  right  side,  entering  inside  the  skin  and  pass- 
ing outside  the  mucous  membrane,  when  the  thread  passed  on  the  left 


576       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

side  is  threaded  into  it  and  now  drawn  into  the  right  side.  This  everts 
the  raw  surface  on  the  one  side  and  brings  it  into  apposition  with  the 
correspondingly  everted  raw  surface  on  the  other  side.  Three  or  four 
sutures  are  thus  passed  and  tied.  The  operation  is  quickly  done  but 
union  may  not  be  thorough  or  broad  enough. 

(3)  Elytroperineorraphy.  This  is  a  favourite  operation  with  many, 
and  helps  at  least  by  enabling  the  patient  to  wear  a  ring  pessary. 

The  patient  is  chloroformed,  placed  in  the  lithotomy  position  and  the 
vaginal  douche  used. 

The  first  thing  to  be  done  is  to  get  a  raw  surface  over  the  site  of  the 
perineal  body  and  lower  portion  of  posterior  vaginal  wall.  The  shape 
of  this  surface  varies  very  much  as  may  be  seen  at  figs.  342  and  343. 

Whichever  is  selected  should  be  mapped  out  by  a  shallow  incision  • 
then  the  raw  surface  formed  by  dissection  with  the  knife,  by  passing  a 
double  cutting  knife  below  the  mucous  membrane,  or  with  scissors.  All 


FIG.  343. 

RAW  SURFACE  AS  MADE  BY  MARTIN.  1234,  raw  surfaces  on  posterior  vaginal  wall;  II,  raw 
surface  round  introitus.  The  surfaces  1-4  are  united,  A  to  A  and  B  to  B.  The  edge  4  |3  is 
turned  in,  with  the  corresponding  one  of  opposite  side,  along  the  line  a.  The  surface  I  II,  is 
united  by  sutures,  so  that  the  English  and  Greek  letters  are  in  apposition  respectively. 

that  is  wanted  is  a  raw  surface  which  should  not  be  excavated,  but  as 
shallow  as  possible.  Bleeding  can  be  stopped  by  the  hot  douche, 
pressure  forceps  or  catgut  ligatures,  if  necessary. 

The  passage  of  sutures  is  important.  Silkworm  gut  is  very  good  and 
may  be  used  both  for  deep  and  superficial  interrupted  stitches.  The 
deeper  sutures  are  passed  first  and  may  go  beyond  the  depth  of  the 
wound  :  then  the  superficial  ones,  beginning  internally.  All  are  passed 
before  being  tied. 

The  continuous  spiral  catgut  suture  is  strongly  recommended  by 
many  and  is  well  worthy  of  trial  (v.  page  560). 

2.  Those  that  aim  at  causing  a  narrowing  of  the  vaginal  walls  or  bring- 
ing about  their  partial  union  (Elytrorraphy). 


PROLAPSUS   UTERI. 


577 


We  may  operate  on  the  anterior  vaginal  wall  only  by  Sims'  method  (fig. 
344) :  or  remove  two  strips  on  each  wall  and  unite  the  opposing  strips 
(Lefort,  Neugebauer).  This  latter  method  may  be  used  in  complete 
prolapsus  cases.  The  strips  may  be  rawed  by  pinching  up  the  necessary 
length  with  long-bladed  forceps  and  cutting  away  what  projects  beyond 
the  grip.  Of  course  this  is  done  with  the  parts  extruded  and  then  the 
opposing  strips  are  united  from  above  down  with  catgut  and  replaced 
as  the  thread  is  tightened. 

Neugebauer  removes  a  mesial  portion  from  the  vaginal  walls,  each 
part  being  about  4  cm.  long  by  1^-2  cm.  broad.  These  surfaces  are 
then  united  to  one  another.  The  long  axis  of  the  raw  surfaces  may 
be  vertical  or  transverse. 


FIG.  344. 

To  SHOW  RAW  SURFACE  AS  MADE  BY  SIMS  (Marion  Simt). 

Each  strip  in  Lefort's  operation  is  6  cm.  by  2  cm. 

3.  It  is  evident  that  we  may  combine  I  and  2. 

4.  The  special  operation  which  aims  at  drawing -up  the  entire  displaceable 
segment  and  uterus   by  shortening  the   round   ligaments   (Aran,  Freund, 
Rivington,  Alexander- Adams  Operation). 

This    operation,  first    performed    in    this    country  by  Rivmgton    < 
London  and  brought  into  prominence  by  Alexander  of  Liverpool  a 
Adams  of  Glasgow,  aims  at  shortening  the  round  ligaments  and  fixin 
them  in  the  inguinal  canal  so  as  to  draw  up  and  fix  somewhat  1 

placed  parts. 
2o 


578       AFFECTIONS  OF  VULVA  AND  PELVIC  FLOOR. 

The  bowels  and  bladder  are  emptied,  the  patient  chloroformed 
and  the  pubes  shaved.  All  antiseptic  precautions  are  to  be  employed 
(Listerism).  The  pubic  spine  is  felt  for  and  an  incision  made  up  and 
out  from  it,  two  inches  in  length  and  in  the  line  of  the  inguinal  canal. 
The  incision  passes  through  skin  and  into  the  external  abdominal  ring, 
known  by  oblique  fibres  crossing  it  and  protrusion  of  fat  at  its  lower 
end.  The  tissue  now  bulging  out  from  the  ring  (the  end  of  the  liga- 
ment) before  entering  the  mons  veneris,  is  lifted  by  an  aneurism 
needle,  grasped  with  the  finger  and  pulled  out  gently,  any  bands 
preventing  this  being  cut  with  the  knife. 

The  other  side  is  treated  in  the  same  way,  both  ligaments  therefore 
being  pulled  out  as  far  as  possible. 

The  wound  is  then  stitched,  the  sutures  (catgut,  silkworm  gut  or 
silver)  being  passed  from  side  to  side  of  incision,  i.e.,  through  skin, 
pillar  of  abdominal  ring,  round  ligament,  pillar  of  ring,  skin.  The  after 
treatment  is  based  on  general  principles  already  laid  down. 

Care  is  to  be  taken  at  first  when  the  patient  moves  about,  and  a  ring 
or  other  suitable  pessary  used  if  necessary. 

Sufficient  is  not  yet  known  about  the  results  of  this  operation,1  and 
from  what  is  known  it  is  falling  into  disfavour.  Deaths  have  been 
recorded  from  it.  One  evident  objection  is  the  risk  of  inguinal  hernia. 

We  may  finally  note  that  in  advanced  prolapsus  uteri  the  uterus  has  been  excised  ;  and 
Miiller  of  Bern  has  performed  abdominal  section,  drawn"up  the  iiterus,  clamped  it  at  the 
isthmus,  removed  the  body  of  the  uterus  and  treated  the  pedicle  extra-peritoneally. 

Neither  of  these  proceedings  is  at  all  to  be  recommended. 

We  recommend  in  treatment 

(1)  Use  of  a  ring  in  slight  cases ; 

(2)  Episioperineorraphy  or  Elytrorraphy  anterior  and  posterior,  and 

a  pessary  in  medium  cases  ; 

(3)  Lefort's  or  Neugebauer's  method  in  advanced  cases. 

The  use  of  massage  in  prolapsus  uteri  will  be  described  in  the  Appendix. 

VAGINAL    ENTEROCELE. 

Of  this  there  are  two  forms,  anterior  and  posterior.  Excessive  intra- 
abdominal  pressure  usually  displaces  all  of  the  pelvic  floor  that  lies  in 
front  of  the  anterior  rectal  wall.  Occasionally,  but  very  rarely,  intes- 
tine is  forced  down  between  the  posterior  aspect  of  the  bladder  and 
upper  part  of  anterior  vaginal  wall,  or  between  the  anterior  rectal  and 
posterior  vaginal  walls  (fig.  345).  We  thus  get  a  mass  bulging  into  the 
vagina,  but  affecting  only  one  wall ;  the  uterus  and  cervix  remain  in 
position.  This  distinguishes  it  from  prolapsus  uteri  and  cervical  elong- 
ation ;  by  rectal  examination,  the  posterior  form  of  enterocele  can  be 
easily  distinguished  from  rectocele. 

1  For  recorded  cases,  see  Index  of  Gynecological  Literature  under  "  Miscellaneous." 


VAGINAL   ENTEROCELE.  579 

The  causation  is  not  well  known.  In  the  posterior  form,  a  deep  dip 
of  the  peritoneum  behind  the  posterior  vaginal  wall  may  have  existed  • 
but  of  this  there  is  no  evidence. 

Treatment.  If  any  ordinary  Albert  Smith  or  anteversion  pessary  fail, 
an  operation  may  be  tried.  In  the  posterior  vaginal  enterocele,  for 
example,  the  protrusion  should  be  replaced ;  a  raw  surface  is  then  made 


FIG.  345. 
POSTERIOR  VAGINAL  EXTEROCELE  (Brewky). 

on  the  posterior  lip  of  the  cervix  and  a  portion  of  the  posterior  vaginal 
wall  about  its  middle ;  these  surfaces  are  then  stitched. 

Prolapsus  uteri  and  both  forms  of  vaginal  enterocele  are  therefore 
essentially  the  same  in  nature,  viz.,  hernial.  Intra-abdominal  pressure 
usually  displaces  all  in  front  of  the  anterior  rectal  wall ;  but  may  also 
force  intestine  in  front  of  the  anterior  vaginal  wall,  or  behind  the 
posterior  one. 


SECTION    VIII. 

DISTURBANCES  OF  THE  MENSTRUAL  FUNCTION. 
CHAPTER  L.    Amenorrhcea :  Menorrhagia :  Dysmenorrhoea. 


SECTION    IX. 

DISTURBANCE  OF  THE  REPRODUCTIVE  FUNCTION. 

CHAPTER  LI.   Sterility. 


CHAPTER   L. 

AMBNORBHCEA:  MENOBBHAGIA:  DYSMENOBBHCEA. 

THE  three  subjects  to  which  this  section  is  devoted  are  not  diseases,  but 
are  symptoms  of  a  large  number  of  the  more  or  less  well-ascertained 
pathological  conditions  already  considered.  Theoretically,  therefore, 
they  should  not  come  up  for  special  consideration  ;  practically,  however, 
it  is  of  use  to  the  practitioner  to  summarize  the  conditions  causing  these 
symptoms,  and  to  give  some  special  hints  as  to  their  treatment. 

AMENOBBHCEA. 
(For  recent  Literature,  see  Index.} 

This  means  cessation  of  menstruation  during  the  period  between 
puberty  and  the  menopause.  It  is  normal  to  have  Amenorrhoea  during 
pregnancy  and  lactation.  Amenorrhoea  may  be  caiised  by  the  following 
Local  conditions : — 

Causes.  /Absence  or  incomplete  development  of  uterus 

J     and   annexa,    atresia  of  the  genital   canal 
*     '  |      (with  or  without  accumulation  of  the  men- 
!     strual  blood),  state  of  cretinism ; 
(Superinvolution,    simple    atrophy   of    uterus, 

Acquired     ....-<      cystic  ovarian  disease,  extensive  inflamma- 
(     tory  conditions  of  uterus  and  ovaries. 

Constitutional  conditions — such  as  phthisis,  chlorosis,  prematurity  of 
menopause — also  cause  amenorrhcea. 

The  local  conditions  have  already  been  fully  described  under  the 
various  heads ;  we  give  here  only  a  few  hints  as  to  the  investigation  of 
the  causes  of  this  symptom.  When  the  patient  complains  of  never  having 
menstruated  and  there  is  no  constitutional  cause  for  the  amenorrhoea,  the 
question  of  examination  should  always  be  entertained;  abdominal 
palpation  and  rectal  examination  are  employed  to  ascertain  that  there 
is  no  retention  from  atresia.  To  ascertain  the  condition  of  the  uterus, 
a  vaginal  examination  may  be  necessary.  Sudden  cessation  of  the 
menstruation  in  a  women  neither  phthisical  nor  chlorotic  is  usually  due 
to  pregnancy ;  early  sickness,  mammary  and  other  signs  should  be 
looked  for.  Nothing  is  a  sure  sign  of  pregnancy  except  the  characteristic 


AMENORRHCEA.  583 

increase  in  the  size  of  the  uterus,  agreeing  with  the  number  of  periods 


In  cases  where  amenorrhoea  is  due  to  chlorosis,  Blaud's  pills  are  Treatment, 
indicated.     These  contain  sulphate  of  iron  and  carbonate  of  potash  made 
up  as  undernoted ;  as  the  result  of  the  combination,  the  carbonate  of 
iron  is  formed. 

R     Ferri  sulphatis. 

Potassii1  carbonatis  aa  gr.  iiss. 

Mucilaginis  tragacanth.se         q.s. 
Fiat  pilula  :  mitte  tales  96. 
Sig.  Three,  thrice  daily. 

Nine  pills  must  be  taken  per  diem  continuously  for  six  to  eight  weeks, 
by  which  time  a  complete  cure  usually  results. 

Before  the  pills  are  given,  the  state  of  the  tongue  and  bowels  should 
be  looked  to.  If  the  tongue  is  foul  and  the  bowels  constipated,  we  may 
give  the  following  : — 

R     Magnesii  sulphatis  31. 

Quininae1  sulphatis  gr.  xxiv. 

Acidi  sulphurici  dil.  3nj. 

Aquam  ad  5vi. 

Sig.  Tablespoonful  twice  or  thrice  daily. 

This  is  taken  for  a  week.  The  Carlsbad  salts  or  Friedrichshall  water 
may  be  substituted.  This  hint  as  to  the  preliminary  purgation  is  a 
good  one,  and  is  given  by  Milner  Fothergill ;  if  not  attended  to,  the 
result  will  be  disappointing  as  the  iron  will  not  be  so  readily  absorbed  by 
the  intestinal  mucous  membranes. 

Note.  The  original  composition  of  Blaud's  pills  is  as  follows -.—Sulphate  of  iron, 
carbonate  of  potash,  of  each  half-an-ounce ;  marshmallow  root  thirty  grains ;  gum 
tragacanth  q.s.  to  make  120  pills. 

The  following  are  the  proportions  in  the  pill  as  made  by  Messrs  Duncan,  Flock  art, 
&  Co.  of  this  city  :  Ferri  sulph.  siccat.  15,  Potass,  carb.  siccat.  15,  Pulv.  gum.  acacias  3, 
Syrup,  simp.  9 ;  Divide  in  5-gr.  pil. 

Blaud's  pill  gives  a  ferrous  carbonate  and  a  potash  salt,  the  decomposition  taking  pla< 
after  the  pill  is  swallowed. 

In  Vallet's  pill,  which  is  popular  on  the  continent,  the  decomposition  is  effe 
and  the  carbonate  of  iron  thus  freshly  formed  is  used  to  make  the  pill.    The  quantiti 
taken  to  make  Vallet's  pill  are  as  follows :— Protosulphate  of  iron  (in  crystals)  10, 
Carbonate  of  soda  (in  crystals)  12,  White  honey  3,  Sugar  of  milk  3 ;  Divide  in  5-gr.  pil. 

Ringer  recommends  permanganate  of  potash.  The  following  is  a 
good  formula  : 

R     Potassii  Permanganatis. 

Kaolin  aa  gr-  ij- 

Vaselini  q.s. 

Fiat  pilula  :  mitte  tales  xxiv. 
Sig.  One  thrice  daily. 

'  According  to  the  terminology  of  the  new  pharmacopoeia. 


584        DISTURBANCES  OF  MENSTRUAL  FUNCTION. 

These  pills  should  not  be  made  with  any  excipient  containing 
glycerine  or  with  an  oxidizable  substance  as  their  union  would  cause 
combustion. 

Oxide  of  manganese  (manganesii  oxidum  praeparatum)  in  two  grain 
doses  thrice  daily  is  also  excellent. 

MENORRHAGIA. 

Menorrhagia  is  the  term  applied  to  excessive  haemorrhage  at  the 
menstrual  periods  ;  when  the  haemorrhage  is  intermenstrual,  it  is  termed 
metrorrhagia. 
Causes.  The  causes  of  menorrhagia  are  the  following  : — 

Constitutional     .  Haemorrhagic    diathesis,    scorbutic    conditions, 

alcoholism ; 

,0vai'itis,     small     cystic     ovaries,     endometritis, 
I      metritis,  subinvolution,  retroversion  of  uterus, 

Local        .     .     .  j      inversion  of  uterus,  submucous  and  interstitial 

(fibroids,  polypi,  carcinoma  uteri,  sarcoma  uteri, 
incomplete  abortion. 

It  should  not  be  forgotten  that  we  may  have  menorrhagia  in 
cardiac  disease,  and  also  in  hepatic  congestion  (Matthews  Duncan, 
Warner). 

Women  who  are  drunkards  very  often  suffer  from  menorrhagia  owing 
to  the  liver  congestion.  This  may  give  the  practitioner  a  hint  as  to 
the  patient's  habits,  especially  as  those  women  who  drink  always  conceal 
the  failing,  and  often  most  successfully.  When  called  to  such,  there 
is  usually  found  great  epigastric  pain  on  pressure,  tremulous  tongue, 
and  depression  of  spirits,  for  which  their  excuse  is  quite  inade- 
quate. 

Treatment.  The  treatment  of  menorrhagia  is  the  treatment  of  the  condition 
producing  it.  In  cardiac  disease  we  give  digitalis;  and  in  hepatic 
disease  we  may  try  chloride  of  ammonium,  euonymium  or  iridin. 

R     Ammonii  chloridi  5iij. 

Aquae  gvj. 

Sig.  Tablespoonful  thrice  daily. 

R     Euonymii 

vel 

Iridin  gr.  ii. 

Pil.  aloes  et  ferri  q.s. 

Fiat  pilula  :  mitte  tales  xij. 
Sig.  One  at  night. 

In  cases  where   there   is  menorrhagia  due   to  a   simple   congested 


DYSMENORRHCEA.  585 

condition  or  to  a  flabby  state  of  the  uterine  muscle,  we  may  give  the 
following  at  the  menstrual  periods  : — 

R     Ergotinee  j.  jv 

Argenti  oxidi 
Micae  panis 

Fiat  pilula  :  mitte  tales  xij. 
Sig.  One  thrice  daily  as  directed. 

Note  that  it  is  well  not  to  write  "at  the  menstrual  period"  on  the 
prescription,  but  to  put  "as  directed."  When  the  practitioner  is  con- 
sulted as  to  menorrhagia  in  unmarried  women  or  young  girls,  he  should 
first  try  the  ergotin  and  oxide  of  silver  pill.  If  this  fail  and  the  case 
be  urgent,  he  should  request  a  local  examination.  If  this  be  declined, 
the  responsibility  rests  with  the  patient. 

R     Extracti  ergotse  liquidi  gij. 

Sig.  Thirty  drops  as  directed 

or 
R     Ergotini  gr.  iv. 

Fiat  suppositorium  :  mitte  tales  xij. 

Sig,  As  directed. 

Inform  the  patient  that  two  suppositories  are  to  be  passed  into  the 
rectum  each  morning  after  the  bowels  move. 

In  some  cases  the  hypodermic  injection  is  required  (v.  p.  426). 

DYSMENORRHCEA. 

LITERATURE.  Duncan,  Matthews—  Clinical  Lectures :  London,  1886,  p.  141.  Goodell— 
Lessons  in  Gynecology  :  Philadelphia,  1879.  Q-usserow — Menstruation  and  Dysmen- 
orrhoea:  Germ.  Clin.  Lect.,  New  Syd.  Soc.  Tr.,  1877.  Herman,  G.  E.—On  the 
Relation  between  Backward  Displacements  of  the  Uterus  and  Painful  Menstrua- 
tion :  Lond.  Obst.  Trans.,  1882.  Solmvieff—  Decidua  menstrualis :  Archiv  f.  Gyn., 
Bd.  II.,  S.  66.  Schroedci — Die  Krankheiten  der  weiblichen  Geschlechtsorgane : 
Leipzig,  1887.  Simpson,  Sir  J.  Y. — Diseases  of  Women,  p.  225 :  Edin.,  1872. 
Williams,  John — Pathology  and  Treatment  of  Membranous  Dysmenorrhcea :  Lond. 
Obst.  Tr.,  1877.  See  also  Index  of  Recent  Literature  in  the  Appendix. 

Dysmenorrhoea  may  be  defined  as  the  occurrence  of  pain  before, 
during,  or  after  the  menstrual  period. 

The  pain  of  dysmenorrhcea  varies  greatly  in  intensity.  It  may  be  so 
severe  as  to  render  the  sufferer  a  miserable  invalid,  it  may  interfere  with 
her  work  more  or  less,  or  it  may  cause  only  marked  uneasiness.  It  is 
always  advisable  in  cases  of  dysmeuorrhoea  to  ascertain  how  much  the 
pain  interferes  with  the  patient's  occupation  or  whether  it  confines  her 
to  bed.  Note  also  when  the  pain  occurs — prior  to,  during,  or  after  the 
blood-flow ;  in  the  purely  spasmodic  form,  it  is  during  the  flow. 

In  order  to  treat  dysmenorrhoea  intelligently,  we  must  endeavour  to 


586        DISTURBANCES  OF  MENSTRUAL  FUNCTION. 


Forms 

usually 

given. 


Practical 
Varieties. 


ascertain  its  cause  and  try  to  make  ont  how  this  condition  brings  about 
the  pain.  We  know  nothing  at  all  as  to  the  real  cause  of  dysmenorrhcea. 
We  know  that  in  many  instances  it  is  associated  with  certain  pathologi- 
cal conditions,  but  how  these  actually  cause  the  pain  is  as  yet  disputed. 

Some  facts  as  to  menstruation  help  us  in  understanding  dysmenor- 
rhoea.  The  uterus  is  an  erectile  organ  (p.  71),  and  as  the  decidua  men- 
strualis  is  five  or  six  times  thicker  than  the  uterine  mucous  membrane, 
it  is  evident  that  metritis  or  pathological  anteflexion  when  present  will 
hinder  the  erection  and  expansion  of  the  flterus,  and  cause  intense  pain 
analogous  to  the  chordee  of  the  penis  in  gonorrhoea. 

In  normal  menstruation,  a  fluid  made  up  of  blood  and  epithelial  debris 
escapes  from  the  uterus.  Probably,  it  does  not  drain  away  by  mere 
capillary  action  but  is  expelled  by  uterine  contractions.  There  is  no 
absolute  proof  of  this,  but  it  is  a  fair  deduction  from  anatomical  facts 
If  a  patient  be  examined  while  menstruating,  we  may  feel  an  arching  o 
slight  tension  of  the  fornices  indicative  probably  of  uterine  action. 

Dysmenorrhoea  is  usually  divided  into  certain  forms.  It  is  to  b 
regretted  that  this  has  been  done,  because  there  have  not  been  collectec 
pathological  facts  sufficient  to  warrant  a  classification.  The  form 
usually  given  are  the  following : — 

1.  Dysmenorrhoea  associated  with  certain  diatheses,  such  as  th 

gouty  and  rheumatic ; 

2.  Spasmodic  dysmenorrhoea ; 

3.  Membranous  dysmenorrhoea ; 

4.  Dysmenorrhoea  associated  with  inflammatory  conditions  of  the 

uterus,  ovary,  peritoneum  or  cellular  tissue ; 

5.  Ovarian  dysmenorrhoea. 

The  last  term  is  applied  to  certain  cases  which  were  supposed  to  be 
specially  connected  with  the  ovaries  and  which  could  not  be  classifiec 
under  the  preceding  heads.  The  term  is  a  most  unfortunate  one.  I 
assumes  a  cause  for  dysmenorrhoea  which  is  not,  as  yet,  demonstrated 
and,  instead  of  pathological  facts  or  a  confession  of  our  ignorance  o 
them,  gives  us  what  we  have  too  much  of  already — erroneous  termin 
ology. 

So  far  as  our  present  knowledge  goes  we  can  speak  of  foui 
varieties : — 

1.  Spasmodic  dysmenorrhoea ; 

2.  Congestive  dysmenorrhoea ; 

3.  Membranous  dysmenorrhoea ; 

4.  Dysmenorrhoea  associated  with  mal-development  of  the  sexua 

organs,  pyosalpinx,  fibroma   uteri,    rheumatic   diathesis 
and  some  other  unknown  causes. 


DYSMENORRH(EA.  587 

1  and  2.  Spasmodic  and  Congestive  dysmenorrhoea.      Of  these  the  most  The  Erec- 
frequent  cause  is  pathological  anteflexion,  i.e.,  anteflexion  of  the  uterus Expansion 
produced  by  inflammation  in  the  utero-sacral  ligaments  with  cicatrisa-°* the 
tion.     The  pathology,  diagnosis  and  treatment  of  this  affection  is  given  hindered, 
at  pp.  347-356.     We  only  remark  here  that  it  is  a  very  serious  lesion 
owing  to  its  inflammatory  etiology.      From  the  flexion  produced,  we  get 
spasmodic  uterine  contraction  accompanied  with  very  great  pain  and 
expulsion  of  clots.     Two  theories  of  dysmenorrhoea  have  been  already 
explained  (p.  351).     Those  who  hold  the  purely  mechanical  theory  seem 
to  forget  that  fluid  blood  passes  easily  through  a  capillary.     Does  any 


FIG.  346. 

SKETCH  OF  A  DYSMENORRH(F.AL  MEMBRANE  AS  SEEN  UNDER  WATER  (Sir  /.  Y.  Simpson). 

one  believe  that  the  lumen  at  the  flexion  is  less  than  that  of  a  capil- 
lary? 

Spasmodic  contraction   of  the  os  internum   and  constriction  of  the 
cervical  canal  are  also  advanced  as  causes. 

3.  Membranous  dysmenorrhoea.     In  this  condition,  the  superficial  layer  Membran- 
of  the  mucous  membrane  is  cast  oft"  as  a  triangular  sac  or  in  shreds  ofDysmenor. 
a  more  or  less  firm  consistence  (figs.  346,  347).     This  may  result  fromrh 
the  occurrence  of  haemorrhage  in  the  deeper  layers  of  the  mucous  mem- 
brane ;  and  then  we  can  understand  that,  according  to  the  depth,  we 
have  present  no  part  of  the  glands  or  only  their  coecal  extremiti 
(Solowieff  and  Gusserow).     Microscopically,  there  is  excess  of  round  , 
and  fibrillated  tissue  in  the  membrane. 


588        DISTURBANCES  OF  MENSTRUAL  FUNCTION. 

J.  Williams,  who  has  written  ably  on  this  subject,  believes  that, 
owing  to  an  excess  of  fibrous  tissue  in  the  walls  of  the  uterus,  the 
mucous  membrane  is  expelled  in  coherent  shreds.  This  excess  of  fibrous 
tissue  is  due  to  defective  evolution,  sub-involution,  or  metritis.  The 
membrane  is,  further,  never  a  plastic  exudation.  It  is  of  the  greatest 
importance  to  remember  that  it  is  not  a  product  of  conception  and  should 
not  be  mistaken  for  an  early  abortion. 

4.  Dysmenorrhoea  from  other  causes,  as  defective  development  of  uterus, 
pyosalpinx,  etc.  Many  of  these  conditions  are  now  being  elucidated  by 
abdominal  section  undertaken  for  Battey's  and  for  Tait's  operation. 

TREATMENT. 

Cautions        At  the  outset  we  are  met  with  a  difficulty.     As  we  are  usually  con- 
as  to 
Treatment. 


FIG.  347. 

A  DYSMENORRHCEAL  MEMBRANE  LAID  OPEN  (Coste). 

suited  for  Dysmenorrhoea  in  unmarried  women,  the  question  of  the  pro- 
priety of  a  pelvic  examination  comes  up.  As  Duncan  has  said — "  No 
rules  that  I  can  give  you  will  make  up  for  want  of  good  sense  and  good 
feeling  on  your  own  part,  but  I  shall  give  you  some  hints.  The  first  is 
that  you  should,  as  a  rule,  not  resort  to  this  treatment  (by  bougies)  in 
an  unmarried  young  woman  without  the  concurrence  of  three  parties — 
firstly,  your  own  approval ;  secondly,  that  of  the  mother  or  guardian  of 
the  patient;  and,  thirdly,  that  of  the  patient  herself.  All  of  these 
should  be  quite  aware  of  the  circumstances,  and  of  what  it  is  proposed 
to  do." 


DYSMENORRH(EA,  589 

Nothing  can  be  more  reprehensible  than  the  vaginal  examination  of 
unmarried  women  for  trifling  ailments.  When  the  Dysmenorrhoea  is 
slight,  make  no  examination  but  order  some  such  mixture  as  the  follow- 
ing. 

R     Spiritus  chloroformi, 

Spiritus  ammoni£e  aromatici,  aa  533. 

Liquoris  ammonise  acetatis  §i. 

Sig.     Teaspoonful  in  a  wine-glassful  of  hot  water  occa- 
sionally. 

Order  a  hot  hip  bath,  or  the  feet  to  be  put  in  mustard  and  water. 
On  no  account  whatsoever  allow  alcohol  in  any  form  to  be  given.  If  the 
mother  has  been  giving  whisky  and  water  or  gin  and  water,  at  once 
point  out  the  risk  the  patient  is  running.  Do  not  give  morphina,  or 
other  opiate,  unless  driven  to  it ;  always  give  it  yourself  and  hypoder- 
mically,  never  by  the  mouth  or  rectum,  and  give  no  prescription 
for  it. 

When  the  Dysmenorrhcea  is  urgent,  then  an  examination  should  be 
advised ;  the  index  finger  well  oiled  can  usually  pass  in  without  much 
pain. 

If  pathological  anteflexion  is  found,  note  the  amount  of  inflammatory 
disturbance,  the  degree  of  flexion,  and  the  implication  or  non-implication 
of  the  tubes  arid  ovaries.  Begin  by  ordering  blisters  to  the  iliac  regions, 
bromide  of  potassium,  the  glycerine  plug,  and  the  hot  vaginal  douche. 
See  that  the  bowels  are  regulated,  and  soft  motions  secured  by  the  use  of 
liquorice  powder  (Pulv.  glycyrrhizse  co.)  and  occasional  enemata,  and 
that  no  tight  lacing  is  allowed.  Chlorotic  patients  should  be  put  on 
Blaud's  pills  and  digitalis,  and  change  of  air,  when  requisite,  ordered. 
Note  the  effect  of  this  for  some  periods ;  and  then,  if  unrelieved,  pass 
the  sound  or  graduated  bougies  or  use  uterine  dilator.  This  course 
benefits  the  Dysmenorrhcea,  and  it  is  safer  than  the  use  of  stem 
pessaries ;  the  dilatation  by  bougies  seems  to  act  like  the  stretching  of 
the  sphincter  ani  in  fissure  of  the  anus  and  often  gives  brilliant  results. 

Patients  with  neurasthenia  often  suffer  severely  at  the  menstrual 
periods.  Local  treatment  is  contra-indicated,  as  the  dysmenorrhoaa  often 
passes  off  while  the  general  condition  is  improving. 

If  the  Dysmenorrhcea  is  membranous,  treatment  is  of  little  service. 
The  following  prescriptions  may  be  tried. 

R     Liquoris  arsenicalis  3ij- 

Sig.     Three  drops  in  water  thrice  daily  after  food. 

R     Liquoris  arsenii  et  hydrargyri  iodidi  (Donovan's  solution)     3ij- 
Sig.     Five  drops  in  water  thrice  daily  after  food. 

The  action  may  be  analogous  to  that  of  arsenic  in  psoriasis. 


590        DISTURBANCES  OF  MENSTRUAL  FUNCTION. 

Treat  any  endocervicitis  or  stenosis  of  cervix  present.  The  prognosis 
is  unfavourable  as  to  cure.  The  patients  are  not  necessarily  sterile. 

In  the  third  class  of  cases,  Battey's  operation  has  not  given  the  results 
anticipated.  We  have  not  as  yet,  however,  facts  warranting  any  dogmatic 
utterance.  Where  the  ovaries  are  developed  but  not  the  uterus,  with 
serious  menstrual  molimina  resulting  in  consequence,  Battey's  operation 
is  undoubtedly  indicated.  In  cases  of  pyosalpinx,  removal  of  tubes  and 
ovaries  by  abdominal  section  gives  good  results  (v.  p.  212). 

Where  any  diathesis  (rheumatic  or  gouty)  is  supposed  to  influence  the 
Dysmenorrhrea,  guaiac,  colchicum  and  such  specific  drugs  may  be  given. 


CHAPTER    LI. 

STERILITY. 

LITERATURE. 

Duncan,  J.  Matthews— Fecundity,  Fertility,  Sterility  and  allied  topics:  Edinburgh, 
A.  &  C.  Black,  1866.  On  Sterility  in  Women  :  J.  &  A.  Churchill,  1884.  v.  Griine- 
iculdt— Ueber  die  Sterilitat  geschlechtskranker  Fraueu  :  Archiv  f.  Gyn.,  Bd.  VIII., 
S.  414.  Kchrcr— Zur  Sterilitatslehre  :  Beitrage  zur  klinischen  und  experiment- 
ellen  Geburtskunde  und  Gynakologie,  Bd.  II.,  S.  76.  Mailer—Die  Sterilitat  der 
Ehe  :  Billroth  u.  Luecke's  Handbuch  der  Frauenkrankheiten :  Stuttgart,  1885,  S. 
297.  Sims,  Marion— Uterine  Surgery  :  London,  1865.  Simpson,  SirJ.  F.— Obstet- 
rics :  Edin.,  A.  &  C.  Black,  1871,  p.  830.  Whitehead—On  the  causes  and  treatment 
of  abortion  and  sterility  :  London,  1847.  See  also  Index  of  Recent  Literature  in  the 
Appendix. 

THE  reproductive  function  is  the  most  complex  and  subtle  of  all  the 
functions  of  life.  If  we  know  little  about  the  simpler  function  of  men- 
struation so  that  there  is  room  for  great  difference  of  opinion  with 
regard  to  it,  we  know  still  less  of  the  function  of  reproduction.  Of  its 
physiology,  we  know  only  that  it  requires  the  presence  of  ova  and  spermato- 
zoa; of  the  constitutional  influences  affecting  the  vitality  of  these  two  and 
the  conditions  favourable  for  their  conjugation,  even  of  the  place  where 
this  occurs,  nothing  is  known.  Nor  have  we  yet  data  for  studying  the 
general  laws  of  fertility  for  the  human  female.  Much  has  been  done 
by  Darwin  and  others  to  elucidate  these  for  plants ;  little  is  known  of 
them  for  animals,  and  almost  nothing  for  the  human  species. 

Of  the  disturbances  of  the  reproductive  function,  sterility  belongs 
to  Gynecology ;  abortion,  retroflexion  of  the  gravid  uterus  and  extra- 
uterine  gestation  belong  more  properly  to  Obstetrics. 

No  simple  and  yet  complete  definition  of  sterility  can  be  given.     The  Distinction 
word  has  a  quite  different  meaning  as  we  use  it  relatively  or  absolutely.  Ae^^ 
As  the  opposite  of  fertility,  it  includes  cases  in  which  a  child  is  not  born  and  Rela- 
till  many  years  after  marriage  or  the  number  of  children  is  comparatively  sterility, 
few ;  further,  inasmuch  as  the  reproductive  function  covers  gestation  as 
well  as  the  birth  of  a  viable  child,  sterility  includes  all  cases  of  intra- 
uterine  disease  and  death  of  the  embryo  or  foetus,  resulting  in  abortion, 
premature  labour,  or  the  birth  of  a  non-viable  child.     None  of  these 
cases    are    absolutely   sterile,  the   sterility  is  relative.     The  term  also 
necessarily  covers  all  cases  in  which  under  circumstances  favourable  to 
conception,  this  either  has  not  occurred  at  all  or  the  product  has  not 


592     DISTURBANCES  OF  REPRODUCTIVE  FUNCTION. 


Relative 
Sterility. 


Absolute 
Sterility. 


gone  the  length  of  even  an  early  abortion.  Here  the  sterility  is  absolute. 
This  raises  the  question  as  to  when  sterility  is  relative,  and  when 
absolute.  What  is  the  standard  of  fertility  by  which  we  decide  that  a 
woman  is  relatively  sterile  and  measure  the  degree  of  that  sterility? 
When  can  we  say  that  a  patient  is  absolutely  sterile  1 

Relative  Sterility.  At  first  sight,  we  should  be  inclined  to  regard  the 
period  of  child-bearing  as  co-extensive  with  the  period  of  menstruation. 
But  it  is  not  so.  The  period  of  fertility  is  not  co-terminous  with  the 
period  of  menstrual  activity :  it  begins  later  and  ends  earlier,  its  total 
duration  being  about  fifteen  years,  during  which  time  births  take  place 
about  every  eighteen  or  twenty  months.  Its  commencement  is  deter- 
mined by  the  year  of  marriage,  in  this  country  on  an  average  the  twenty- 
fifth  year,  the  first  child  being  born  in  most  cases  twenty  months  after 
marriage.  It  ceases  usually  about  thirty-eight,  some  years  before  the 
menopause.  Thus,  as  Whitehead  puts  it,  there  is  a  period  of  quiescence 
in  the  function  of  reproduction  both  at  the  commencement  and  at  the 
termination  of  menstruation.  (Matthews  Duncan) 

Taking  the  foregoing  considerations  as  giving  us  a  standard  of  fertility, 
we  learn  that  relative  sterility  may  show  itself  in  such  various  ways  as 
these, — not  having  the  first  child  within  twenty  months  after  marriage, 
having  children  at  intervals  of  longer  than  twenty  months,  ceasing  to 
have  children  within  fifteen  years  after  marriage.  In  applying  these 
considerations  to  an  individual  case,  however,  we  must  of  course  take 
into  account  the  age  of  the  patient.  There  seems  also  to  be  great  varia- 
tion in  the  productive  power  of  different  individuals.  One  patient  has 
many  children  without  injury  to  health,  while  in  another  the  birth  of 
one  child  exhausts  the  reproductive  function.  Sir  James  Simpson 
found  that  among  British  peers  unproductive  marriages  are  relatively 
more  common  (1  in  6,  instead  of  1  in  10).  As  the  result  of  relative 
sterility  we  find  that  the  number  of  children  to  a  marriage  in  Britain 
is  5*2  or  one-half  of  what  it  would  be  if  all  the  conditions  favourable  to 
reproduction  were  fulfilled. 

Absolute  Sterility.  The  interval  between  marriage  and  the  birth  of 
the  first  child  averages  twenty  months,  and  any  protraction  of  this 
interval  means  a  degree  of  sterility ;  but  we  cannot  speak  of  absolute 
sterility  until  several  years  of  married  life  have  passed  without  even  an 
abortion.  Matthews  Duncan  found  in  his  statistics  of  the  births  in 
Edinburgh  and  Glasgow  for  the  year  1855,  an  average  interval  of  17 
months  to  the  first  child — two-thirds  being  born  before  the  end  of 
the  second  year,  and  only  one-twenty-fourth  after  the  fourth  year. 
Hence,  he  concludes  that  there  is  no  ground  for  the  assumption  of  per- 
sistent sterility  until  the  fourth  year  of  married  life  has  been  entered 
upon. 

Of  the  number  of  absolutely  sterile  marriages  in  Britain  we  have  no 


STERILITY.  593 

data.  The  statistics  of  Sir  J.  Y.  Simpson,  based  on  the  reports  of  the 
population  of  Grangemouth  and  Bathgate  which  give  the  number  of 
sterile  marriages  as  1  in  10,  include  abortions  and  all  other  cases  in 
which  a  child  would  not  be  registered,  so  that  they  cannot  be  relied 
upon  for  data  regarding  absolute  sterility. 

The  Etiology  of  Sterility  is  too  wide  a  subject  to  be  exhaustively  dis- Etiology  of 
cussed  here.     We  can  only  indicate  what  the  causes  are  and  point  outsterility- 
the  necessity  of  taking  a  broad  view  of  this  question. 

Amongst  general  influences,  we  note  first  of  all  the  effect  of  temperature 
and  climate,  and  of  marriage  between  near  relatives.  Under  want  of 
sexual  agreement  have  been  placed  many  cases  which  have  not  been  ex- 
plained otherwise  (such  as  the  classical  one  of  Napoleon  and  Josephine). 
Age  has  an  undoubted  influence ;  the  period  of  nubility  is  from  the  age 
of  twenty  to  twenty-five,  and  marriages  before  or  after  this  period  are 
less  fertile.  The  influence  of  disturbed  nutrition  is  seen  in  the  associa- 
tion of  sterility  with  obesity ;  it  seems  that  the  taking-on  of  fat  is  at 
the  expense  of  the  reproductive  function,  perhaps  through  interference 
with  ovulation.  Chlorotic  patients  are  also  sometimes  sterile.  The 
association  of  Dysmenorrhoea  with  sterility  has  been  already  referred  to 
(pp.  267  and  352)  and  is  a  matter  of  everyday  observation.  Matthews 
Duncan  found  spasmodic  dysmenorrhoea  in  47'9  (159  out  of  332)  of  his 
cases  of  sterility;  while  Marion  Sims  found  it  in  51 '6  p.c.  (129  out  of 
250)  of  his.  Further,  these  conditions  disappear  together  under  treat- 
ment, and  spasmodic  dysmenorrhoea  is  a  rare  condition  in  fertile  women. 

As  to  local  causes,  we  note  that  sterility  is  found  associated  with  the 
following  conditions  already  described  : — vaginismus,  p.  530 ;  hypertro- 
phied  cervix,  p.  280  ;  conical  cervix  with  pin-hole  os,  p.  265 ;  cervical 
catarrh,  p.  308 ;  anteflexion,  p.  350 ;  retroflexion  (more  rarely),  p.  366 ; 
endometritis,  p.  323  ;  ovaritis,  p.  203 ;  pelvic  peritonitis,  p.  162.  The 
last  three  are  probably  the  most  important.  Taking  the  function  of 
reproduction  instead  of  the  various  organs  as  the  standpoint  from  which 
to  regard  sterility,  we  find  that  this  function  may  be  divided  into  three 
processes — Insemination,  Impregnation  of  the  ovum  or  Conception,  and 
Gestation.  A  certain  number  of  cases  of  sterility  are  due  to  defect  in 
Insemination  (e.g.  all  cases  of  Dyspareunia) ;  but  the  most  important 
group  of  cases  coming  under  this  head  are  those  of  absence  or  deficient 
vitality  of  the  Spermatozoa.  As  we  are  dealing  here  only  with  sterility 
in  the  female,  this  last  cause  of  sterility  is  beyond  our  subject ;  but  it  is 
important  to  remember  that  Gross's  investigations  into  male  sterility 
show  that  it  is  probably  the  cause  in  every  sixth  case  which  comes 
before  us.  As  to  the  relative  importance  of  Conception  and  Gestation, 
the  investigations  of  v.  Griinewaldt  show  that  interference  with  the  latter 
is  a  much  more  important  factor  in  sterility  than  is  generally  supposed. 
Investigating  500  cases  of  sterility  from  the  standpoint  of  the  influence 
2  P 


594    DISTURBANCES  OF  REPRODUCTIVE  FUNCTION. 

that  the  condition  of  the  uterine  tissue  has  on  gestation,  he  comes  to 
the  following  conclusion : — Conception  forms  only  one  link  in  the  chain 
of  processes  involved  in  the  fertility  of  marriage,  and  is  of  slight  import- 
ance compared  with  the  great  number  of  vital  processes  implied  in  ges- 
tation ;  the  point  of  greatest  importance  in  the  fertility  of  woman  is  her 
capability  of  carrying  a  fertilised  ovum,  which  depends  to  a  great  extent 
on  the  integrity  of  the  uterine  tissue. 

Kleinwachter l    met  with  one-child  sterility  in  8'32  p.c.  of  his  cases.      The  age  at 

which  the  women  married  seemed  to  have  nothing  to  do  with  it.  He  finds  that  the 
causes  are  the  same  as  in  the  case  of  absolute  sterility  (apart  from  congenital  malforma- 
tions), viz.  : — 

Inflammation  after  puerperium,  .            .            .  .  17 '77  p.c. 

„       not    „            „  .             .            .  .  12-22 

Endometritis,    .            .            .  .            .            .  .  17 '77 

Uterine  displacements,             .  .            .            .  .  12 '22 

,,        neoplasms,       .            .  .            .            .  .  8 '88 

Constitutional  conditions,        .  .            .            .  .  7 '77 

Male  impotence,           .            .  .            .            .  .  7 '77 

Uterine  atrophy,           .            .  .            .            .  .  5 '55 

Ovarian  neoplasms,       .            .  .            .            .  .  3 '33 

Unknown  causes,           .            .  .            .            .  .  6 '66 

Treatment.  In  the  treatment  of  sterility,  we  must  take  a  broad  view  of  the  etiology 
and  not  allow  local  conditions  to  influence  us  unduly.  Attention  to  the 
general  health,  and  patient  waiting  until  at  least  three  years  of  married 
life  have  passed  is  all  that  is  required  in  the  large  proportion  of  cases. 
Entire  cessation  of  intercourse  for  several  months  should  be  recommended, 
and  can  be  secured  by  change  of  air  to  some  watering-place  at  home  or 
abroad,  according  to  the  patient's  means.  Where  coitus  is  impossible 
or  painful  (as  in  cases  of  atresia  and  vaginismus)  operative  interference 
is  called  for  immediately,  and  such  cases  offer  the  most  satisfactory 
results  in  treatment  (see  p.  520).  In  estimating  the  importance  of 
operations  on  the  cervix  (p.  269),  we  must  keep  in  view  the  rarity  of  this 
indication  for  treatment  and  the  uncertainty  that  an  operation  by 
dilatation  or  division  will  be  beneficial.  Whether  the  sterility  be  due 
to  the  rigid  condition  of  the  cervix  or  the  smallness  of  the  os  externum, 
such  cases  form  only  4  p.c.  (Mutter)  or  8  p.c.  (Kehrer)  of  the  total 
number  of  women  who  seek  advice  for  sterility.  In  other  words,  taking 
Miiller's  statistics  the  chances  are  24  to  1  that  the  cause  of  sterility 
must  be  sought  elsewhere  than  in  the  cervix. 

1  Centralb.f.  Gyn.,  XII.,  287. 


SECTION    X. 

AFFECTIONS   OF   BLADDER  AND   RECTUM. 

CHAPTER    LIT.  The  Bladder :   Anatomy,  Physiology,  and  Methods  of 

Examination. 

„        LIII.  Affections  of  the  Urethra  and  Bladder. 
„         LIV.  Vesico- Vaginal  Fistula. 
,,          LV.  The  Rectum  :  Coccygodynia. 


APPENDIX. 

Abdominal  Section. 

Electricity  in  Gynecology. 

Systematic  Treatment  of  Nerve  Prostration. 

Hysteria  and  Hystero-Epilepsy. 

Massage. 

Relation  of  Gonorrhoea  to  Gynecology. 

Case-Taking. 

Sources  of  Gynecological  Literature. 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE. 


CHAPTER   LIL 

THE  BLADDER :  ANATOMY,  PHYSIOLOGY  AND  METHODS 
OF  EXAMINATION. 

L1TERA  TURE. 

Burckhardt — Endoskopie  und  endoskopische  Therapie :  Tubingen,  Laupp'schen  Buch- 
handlung.  Chiene — Bladder  Drainage:  Ed.  Med.  Jour.,  1880.  Groom,  J.  H. — 
On  Retention  of  Urine  in  the  Female :  Ed.  Med.  Jour.,  April  and  May  1878. 
Femoick,  E.  H. — The  Electric  Illumination  of  the  Bladder  and  Urethra  :  London, 
Churchill,  1888.  Foulis — An  Antiseptic  Catheter  for  washing  out  the  Bladder : 
Brit.  Med.  Jour.,  Jany.  30,  1886.  Hart— Physics  of  Rectum  and  Bladder  :  Ed.  Obst. 
Trans.,  1882.  Nitze — Lehrbuch  der  Kystoskopie :  Wiesbaden,  1889.  Noegyerath 
— The  Vesico-vaginal  and  Vesico-rectal  Touch  :  Am.  J.  of  Obstet. ,  viii. ,  135.  Ogston 
— Ed.  Med.  Jour.,  1878.  Pawlik — Ueber  die  Harnleitersondirung  beim  Weibe  : 
Archiv  f.  klinische  Chirurgie,  Bd.  XXXVI.,  Hft.  2.  Power— Physiology  of  Mic- 
turition :  The  Practitioner,  1875.  Stinger — Ueber  Tastung  der  Harnleiter  beim 
Weibe:  Archiv  f.  Gyn.,  Bd.  XXVIII.,  S.  54.  Skene— Diseases  of  the  Bladder  and 
Urethra  in  Women  :  W.  Wood  &  Co.,  New  York,  1878.  Winckel— Die  Krankheiten 
der  weiblichen  Harnrohre  und  Blase  :  Billroth's  Handbuch,  Stuttgart,  1886. 

DISEASES  of  the  bladder  are  of  the  greatest  importance  as  they  are  not 
only  very  painful,  but,  for  a  reason  to  be  given  shortly,  very  intractable. 
In  a  Manual  of  the  present  scope,  a  full  consideration  of  vesical  disease 
is  impossible  ;  we  therefore  give  a  mere  sketch,  and  refer  the  practitioner 
for  details  to  Skene's  or  to  Winckel's  Manual. 

ANATOMY   AND    PHYSIOLOGY. 

Physiology      For  the  anatomy,  the  student  is  referred  to  pp.  30  to  35.     We  should 
£jourina~    here  only  point  out  that  the  female  bladder,  owing  to  its  greater  breadth 
transversely  at  the  base  (v.  fig.  359),  is  relatively  more  capacious  than 
that  of  the  male. 

Urination.  The  mechanism  of  the  storage  and  expulsion  of  urine 
from  the  bladder  is  full  of  interest,  both  from  a  theoretical  and  a  practical 
point  of  view.  The  urine  trickles  along  the  ureters,  a  result  partly  due 
to  blood  pressure  and  partly  to  the  peristaltic  action  of  the  ureters  them- 
selves. It  thus  reaches  the  bladder,  at  this  stage  an  empty  flaccid  sac 
with  its  upper  half  fitting  into  the  lower  calyx-like  portion.  Gradually 
the  bladder  distends,  until  at  last  the  activity  of  the  motor  centre 
(whose  constant  action  keeps  the  urethral  muscles  contracted)  is  reflexly 
inhibited,  and  the  urine  is  expelled  by  the  muscular  contraction  of  the 
bladder  and  intra-abdominal  pressure.  The  bladder  is  now  contracted 


ANATOMY  AND  PHYSIOLOGY  OF  BLADDER.        597 

and,  on  section,  has  the  shape  seen  at  fig.  348 — its  shape  in  systole. 
The  bladder  then  relaxes,  i.e.,  becomes  flaccid — its  diastole,  and  once 
more  the  urine  trickles  into  it  (fig.  25). 

The  bladder  therefore  has,  like  the  heart,  its  systole  and  diastole.  A 
knowledge  of  this  is  important  practically.  It  explains  the  intract- 
ability of  inflammatory  conditions  of  the  bladder,  since  the  bladder 
when  inflamed  does  not  get — what  every  inflamed  organ  requires — rest. 


FIG.  348. 

BLADDER  is  SYSTOLE  (Brav.nt). 

The  average  amounts  of  the  several  urinary  constituents  passed  inComposi- 
twenty-four  hours,  as  given  by  Parkes,  are  the  following  : —  Urine> 


Water 
Total  solids 
Urea  . 
Uric  acid     . 
Hippuric  acid 
Kreatinin    . 
Pigment,  etc. 
Sulphuric  acid     . 
Phosphoric  acid  . 
Chlorine 
Ammonia    . 
Potassium  . 
Sodium 
Calcium 
Magnesium          . 


1500-000  Grms. 

72-000 

33-180 

•555 

•400 

•910 

10-000 

2-012 

3-164 

7-000 

•700 

2-500 

11-090 

•260 

•207 


598    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Urine  also  contains  various  epithelial  scales,  a  little  mucus,  nitrogen 
and  carbonic-acid  gases. 

The  reaction  is  acid,  and  the  specific  gravity  is  1020. 

METHODS  OF  EXPLORING  THE  URETHRA. 

The  urethra  is  explored  by  sound,  finger,  and  speculum  in  the  same 
way  as  the  bladder.  We  need  not  therefore  go  into  detail  in  these, 
but  refer  the  student  to  methods  of  exploring  the  bladder. 

We  may  remark,  however,  that  the  exploration  by  finger,  sound,  or 
speculum  is  not  very  satisfactory  in  the  case  of  the  urethra,  as  polypi 
become  flattened  against  the  urethral  wall  by  finger  or  speculum  and 
are  thus  overlooked.  In  such  cases  the  button-hole  operation  of  Emmet 
is  useful  and  is  performed  as  follows. 

The  patient  is  put  in  the  lithotomy  posture  and  a  sound  of  calibre 
sufficient  to  stretch  the  urethra,  passed.  The  object  of  the  operation 


FIG.  349. 

EMMET'S  BUTTON-HOLE  OPERATION  ON  THE  URETHRA  :  the  patient  is  supposed  to  be  on  her 
side  and  Sims'  Speculum  passed  (Emmet). 

is  to  incise  the  urethra  vertically  and  mesially  but  not  to  touch  the 
meatus  urinarius  or  neck  of  the  bladder.  The  urethra  is  If  inches 
long,  and  therefore  an  incision  of  the  vaginal  tissues  over  the  urethra 
f-  of  an  inch  in  length  will  avoid  the  urethral  orifice  and  neck  of  bladder. 
The  vaginal  tissue  is  caught  up  with  a  tenaculum  and  divided  down 
to  its  canal.  The  scissors  are  now  used  to  extend  this  up  towards  the 
neck  of  the  bladder  and  down  towards  the  urethral  orifice.  The 
incision  in  the  vaginal  mucous  membrane  should  be  one-third  longer 
than  that  into  the  urethral  canal,  and  the  extra  length  should  be  at 
the  bladder  end. 

No  incontinence  of  urine  is  produced  if  the  neck  of  the  bladder  be 
uninjured. 

Through  this  incision  polypi  can  be  detected  and  removed,  prolapse 


EXPLORATION  OF  URETHRA  AND  BLADDER.       599 

of  the  urethra!  mucous  membrane  can  be  excised,  and  medicaments 
applied. 

Should  the  incision  be  made  merely  for  temporary  purposes  it  can  be 
closed  by  silver  stitches  including  the  mucous  membrane  of  the  urethra. 
When  the  operator  wishes  to  make  a  urethro-vaginal  fistula  for  purposes 
of  treatment,  he  unites  the  edges  of  the  mucous  membrane  of  the  vagina 
to  the  corresponding  edge  of  the  urethral  mucous  membrane  by  means 
of  catgut  or  silk  (Button-hole  operation — fig.  349).  This  fistula  can 
be  closed  when  necessary  in  the  ordinary  way. 

For  dilatation  by  Simon's  specula,  see  page  600. 

METHODS    OF    EXPLORING   THE   BLABBER. 

A.   By  Catheter  and  Sound. 

The  catheter  is  passed  for  the  purpose  of  drawing  off  the  urine,  while 
the  sound  is  usually  employed  for  diagnostic  purposes — ascertaining  the 
state  of  the  mucous  membrane,  the  presence  of  stone  or  other  patho- 
logical conditions. 

Method  of  passing  the  catheter.  The  instrument  to  be  employed  for 
this  purpose  is  a  male  gum-elastic  catheter,  No.  8  or  10.  In  some 
special  cases,  a  silver  instrument  is  required.  Battey  recommends  a 
long  rubber  catheter  as  a  very  useful  instrument.  The  catheter  must 
first  be  thoroughly  washed  with  carbolic  lotion  (1-20),  or  corrosive  sub- 
limate (1-2000),  and  then  its  end  dipped  in  glycerine  and  corrosive 
sublimate  (1-2000).  Cleanliness  in  the  use  of  catheter  is  of  the  very 
highest  importance,  as  cystitis  and  even  pyaemia  may  be  caused  in 
old  people  by  urine  rendered  putrid  by  the  catheter. 

The  patient  lies  on  the  left  side  square  across  the  couch,  with  the 
hips  at  the  edge  and  the  knees  drawn  up.  The  pulp  of  the  index  finger 
of  the  left  hand  is  passed  over  the  base  of  the  perineal  body  and 
onwards  until  it  touches  the  vestibule.  It  should  then  be  carried  a 
little  backwards  until  we  feel  the  meatus  at  the  base  of  the  smooth 
vestibule  and  in  the  middle  line.  The  catheter  is  passed  with  the  right 
hand ;  the  index  of  the  left  hand  feels,  through  the  anterior  vaginal 
wall,  that  it  passes  into  the  urethra.  After  the  last  drop  of  urine  has 
been  expelled,  the  catheter  is  withdrawn  and  the  finger  held  over  its 
proximal  end  so  as  to  retain  the  fluid  remaining  in  the  catheter  until  it 
can  be  poured  into  a  receptacle. 

The  catheter  may  also  be  passed  with  the  patient  lying  on  the  back  ; 
the  index  of  the  right  hand  is  carried  under  the  drawn-up  right  thigh 
to  feel  the  meatus,  and  the  catheter  is  passed  between  the  thighs  with 
the  left. 

Battey's  catheter  is  very  convenient,  as  from  its  length  it  reaches 
the  floor  and  can  be  withdrawn  without  any  precaution  as  to  spilling. 


600    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Further,  it  is  easily  cleaned ;  to  do  this  it  is  coiled  up  in  a  bowl  of 
1-20  carbolic  lotion,  and  then  when  one  end  is  brought  over  the  edge 
it  empties  by  syphon  action.  The  indications  for  the  catheter  are  the 
various  causes  of  retention  of  urine  (v.  p.  614);  at  present  we  only 
remark  that  it  should  never  be  passed  unless  necessary,  and  that  the 
greatest  care  should  be  taken  not  to  introduce  septic  matter.  Recently 
Foulis  has  recommended  a  special  apparatus  for  washing  out  the 
bladder  which  may  be  used  for  drawing  off  the  urine  also. 

B.  Digital  and  Specular  Exploration  of  the  Bladder. 

Owing  to  the  large  amount  of  muscular  and  elastic  tissue  in  the 
urethra,  it  can  be  stretched  to  an  extent  that  permits  of  digital  and 
specular  examination  of  the  urethal  and  vesical  lining  membrane. 

Digital  examination.     With  the  patient  lying  in  the  lithotomy  posture 

d  under  chloroform,  the  tip  of  the  little  finger  is  placed  against  the 
finger,  meatus  and  by  a  rotary  motion  passed  through  it  in  the  direction  of  the 
urethral  axis.  The  meatus  is  the  most  resistant  portion  of  the  urethra ; 
therefore,  to  aid  in  its  dilatation,  some  recommend  to  notch  it  with 
radiating  nicks.  This  is  unnecessary  (A.  R.  Simpson).  By  steady  pres- 
sure, the  little  finger  is  first  pushed  in  and  then  the  index  one  substi- 
tuted. Hegar's  dilators  for  the  cervix  are  of  great  use  here  also.  For 
exploratory  purposes,  this  is  sufficient ;  to  complete  the  examination,  how- 
ever, the  Bimanual  should  be  performed  as  shown  at  fig.  67.  This  is  aided 
by  the  middle  finger  in  the  vagina,  and  is  therefore  termed  the  vesico- 
vaginal  Bimanual.  Instead  of  chloroform,  cocaine  may  be  injected  locally. 

The  presence  of  stone  or  of  tumours,  the  state  of  the  mucous 
membrane  of  the  bladder,  the  nature  of  obscure  bodies  in  front  of  the 
uterus  can  all  be  thoroughly  ascertained ;  vesico-vaginal  fistulse  can 
be  examined  if  the  vagina  has  been  obliterated  ;  intestino-vesical 
fistulae  can  be  detected ;  calculi,  impacted  in  the  vesical  portion  of  the 
ureters,  can  be  removed ;  fissures  of  the  neck  of  the  bladder  can  be 
stretched  ;  Winckel  adds  to  these  that  we  can  open  a  hsematometra 
through  the  bladder,  when  its  evacuation  between  the  bladder  and 
rectum  is  impossible — a  very  rare  indication.  The  Fallopian  tubes  can 
be  felt  with  the  finger  in  the  bladder  (Noeggerath] ;  and,  in  one  special 
instance,  Groom  proved  by  this  method  that  the  sound  had  perforated 
the  walls  of  the  thin  superinvoluted  uterus  and  had  not  passed  along 
the  Fallopian  tube. 

with  Simon's  methods  of  specular  dilatation  of  urethra.     Simon  of  Heidel- 

Specula.  berg  drew  gpecjai  attention  to  the  dilatation  of  the  urethra  by  his 
specula  as  a  means  of  treatment.  The  object  is  to  dilate  the  urethra 
sufficiently  to  allow  of  the  passage  of  calculi,  crushed  or  uucrushed. 
By  it  we  also  destroy  temporarily  the  sphincteric  action  of  the  urethra 
and  thus  cause  incontinence  of  urine :  this  allows  to  the  inflamed 


EXPLORATION  OF  URETHRA  AND  BLADDER.   601 

mucous  membrane,  now  undisturbed  by  the  frequent  muscular  contrac- 
tions which  before  were  necessary  to  expel  the  urine,  the  rest  it  needs. 
The  difficulty  of  Simon's  method  is  the  risk  of  causing,  by  over-stretching, 
permanent  incontinence  of  urine — a  condition  as  yet  uncurable. 


FIG.  349.* 

SIMON'S  URKTHKAL  SPECULA  (Winckd). 


Simon's  specula  are  shown  at  fig.  349*  and  the  various  sizes  at  ng.Sun.ns 
350      The  specula  are  provided  with  bulbous  plugs,  to  be  used  whi 
they  are  being  introduced  and  afterwards  withdrawn.     Simon  « 

oooOOO 


FIG.  350. 


.riv»«    vw» 

THE  VARIOUS  SIZES  OF  SIMON'S  SPECULA  (Wincket). 

the  limit  of  safe  disability  for  the  female  urethra 
follows  --Adults,  6-6-25  cm.  (2TV^TV  in.)  i" 
cm.  (f  in.)  in  diameter;    young  women  (of 


-3        . 


602 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


in  circumference,  or  1-8-2  cm.  (f  in.)  in  diameter;  girls  (of  11-15 
years),  4 -7-5-6  cm.  (1|~2^  in.)  in  circumference  or  1-5-1 '8  cm.  (T9F  in.- 
y^  in.)  in  diameter. 

Practically,  we  find  that  the  index  finger  can  be  passed  with  safety  ; 
and  that  any  dilatation  beyond  an  inch  diameter  is  dangerous  in  regard 
to  permanent  incontinence. 

Persistent  incontinence  has  attended  the  extraction  of  stones  with  a 
diameter  of  If  in.,  but  Dunlap  x  has  recorded  a  case  where  a  stone  2£  in. 
in  diameter  was  safely  extracted  uncrushed  through  the  urethra  without 
consequent  incontinence  of  urine. 

The  dilators  of  Simon  are  graduated,  and  are  passed  slowly  until  the 
desired  limit  is  reached. 


Skene's 
Specula. 


FIG.  351. 

SKENE'S  URETHRAL  SPECULA  (Skene). 

It  is  doubtful  if  they  can,  without  risk,  be  used  as  Simon  recommends. 

Specular  examination  by  Skene's  specula.  Fig.  351  shows  Skene's 
specula.  Each  may  be  described  as  a  small  test  tube  which  fits  into  a 
truncated  or  fenestrated  case  of  vulcanite.  The  glass  tube  projects 
beyond  the  outer  truncated  case ;  and  a  small  mirror  can  be  carried 
through  the  inner  tube  so  as  to  reflect  light. 

Skene's  directions  are  to  pass  the  tube  (with  mirror  inside)  along  the 
urethra,  and  to  use  sun-light  or  gas-light  from  a  movable  bracket. 
When  a  large  Skene's  speculum  is  used,  the  urethra  should  be  first 

1  Am.  J.  of  Obsl.,  Vol.  XIV.,  p.  855. 


EXPLORATION  OF  URETHRA  AND  BLADDER.       603 

dilated  -with  the  index  finger.  When  viewed  through  the  speculum,  the 
mucous  membrane  of  the  bladder  is  somewhat  pale. 

The  hard  rubber  speculum  can  be  used  in  making  applications. 

A  specially  narrow  Fergusson's  speculum  with  a  hand  mirror  is  also 
simple  and  useful  (M.  Duncan). 

c.  Catheterisation  of  the  ureter. 

This  is  by  no  means  an  easy  operation,  but  is  useful  in  certain  cases. 

Method  of  Performance.     Pass  the  index  finger  into  the  bladder  asCatheteri- 
already  described  (p.  600) ;  about  an  inch  from  the  neck  of  the  bladder  ureter°f 
and  at  each  end  of  the  inter-ureteric  ligament,  a  prominence  (in  which 


FIG.  352. 

FlKfFR   PASSFD   THROUGH   URETHRA   INTO   BLADDER  TO   GUIDE   HOLLOW    PROBE   INTO  LEFTlURBTER. 

« ^Internal  SphFnctei °of  Urethra,  I  Orifice  of  right  Ureter,  c  Inter-ureteric  Ligament  ( WwM). 

is  the  vesical  opening  of  the  ureter)  can  be  felt  with  the  pulp  of  the 
examining  finger.      A  fine  hollow  probe  is  guided  into  this  and  its  point 
carried  to  the  side  (fig.  352).     The  urine  will  now  trickle  out  drop  by 
drop.      According  to  Pawlik,1  the  inter-ureteric  ligament  can  b 
through  the  anterior  vaginal  wall  when  the  patient  is  m  the   gei 
pectoral  posture.     He  thus  passes  the  ureteric  catheter  withou 
the  urethra. 

1  Centr.f.  Gyn.,  Oct.  15,  1881. 


604    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Electric  Endoscope. 

This  handy  and  convenient  instrument  has  now  been  used  with  great 
success  in  the  diagnosis  of  vesical  conditions.  It  would  take  up  too 
much  space  to  describe  its  construction  and  use  fully  :  these  can  be 
found  in  the  special  works  on  this  subject.  We  may,  however,  state 
that  the  instrument  has  been  brought  to  its  present  value  chiefly  by  the 
labours  of  Nitze  and  Leiter,  and  that  the  introduction  of  the  small 
incandescent  lamp  as  the  illuminating  agent  has  probably  been  the 
greatest  improvement. 

By  this  means  we  can  ascertain  the  position  of  the  ureter  in  operating 
on  vesico-vaginal  fistula  and  prior  to  excision  of  the  cancerous  uterus ; 
and  in  proposed  excision  of  a  kidney  we  can  ascertain  the  state  of  the 
other  kidney  by  examination  of  the  urine  from  it. 


CHAPTER  LIU. 

AFFECTIONS  OF  THE  URETHRA  AND  BLADDER. 
For  LITERATURE,  see  CHAPTER  LI. 

MALFORMATIONS   OF   THE   URETHRA  AND   BLADDER. 

THESE  comparatively  rare  malformations  are  easily  understood  on  con- 
sideration of  the  development  of  the  organ. 

The  bladder  is  the  part  of  the  allantois  included  by  the  abdominal 
plates  of  the  embryo  (figs.  317  to  321);  the  upper  portion  of  the  pos- 
terior wall  of  the  urethra  is  formed  by  Miiller's  ducts,  while  the  lower  is 
formed  by  an  invagination  from  the  genito-urinary  sinus.  The  develop- 
mental defects  are  therefore  the  following : — 

(1)  Total  absence  of  urethra ; 

(2)  Defect  of  external  portion  of  urethra — hypospadias ; 

(3)  Defect  of  internal  portion  of  urethra ; 

(4)  Atresia  of  the  urethra  (in  malformed  foetuses) ; 

(5)  Extroversion  of  the  bladder  from  deficient  closure  of  the 

embryonic  abdominal  plates. 

We  would  here  only  note  the  rarity  of  these  conditions,  and  refer  the 
practitioner  to  Skene  or  Winckel  for  details. 

DISEASES    OF    THE    URETHRA. 

Of  these  the  most  important  are  Displacements,  Neoplasms,  Urethritis, 
Dilatation,  and  Stricture. 

DISPLACEMENTS. 

These  will  be  easily  understood  by  reference  to  those  of  the  bladder. 

Urethrocele  is  a  pouching  of  the  urethra  and  vaginal  wall  allowing  the 
lodgment  of  stale  urine.  It  is  treated  by  excising  a  portion  of  the 
urethral  wall  and  uniting  the  edges  by  stitches. 

Prolapse  of  the  mucous  membrane  of  the  urethra  through  the  urethral 
orifice  may  be  remedied  by  the  button-hole  operation.     The  incision  u 
made  down  to  the  submucous  tissue,  and  the  mucous  membrane  pulle 
through  this  until  the  excess  at  the  urethral  orifice  disappears. 
excess  at  the  button-hole  is  then  cut  off  and  the  wound  stoned. 


606 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


Urethral 
Caruncle. 


NEOPLASMS  OF  THE  URETHRA  ;  URETHRAL  CARUNCLE. 

The  urethra  is  liable  to  be  invaded  by  papillomata,  polypi,  sarcomata, 
(cysts),  carcinomata,  and  vascular  growths  (angiomata). 

Of  these  last,  the  most  common  is  the  well-known  Urethral  Caruncle. 

Pathology.  This  is  a  vascular  excrescence  varying  in  size  from  a  piu 
head  to  a  strawberry ;  it  consists  of  dilated  capillaries  in  connective 
tissue,  the  whole  being  covered  with  squamous  epithelium.  Physical 
Signs.  A  cherry-red  tumour,  exquisitely  tender  and  vascular,  is  seen  at 


FIG.  353. 

CARUNCLE  AT  URETHRAL  ORIFICE  (a)  AND,  IN  ADDITION,  NEUROMATA  IN  SURROUNDING  Mucous 
MEMBRANE— see  page  518  (Sir  /.  Y.  Simpson). 

the  urethral  orifice  (fig.  353).  Symptoms.  These  are  pain  on  micturi- 
tion or  even  retention  of  urine,  and  pain  on  coitus.  Treatment.  Place 
the  patient  under  chloroform  in  the  lithotomy  posture,  and  destroy  the 
growth  by  Paquelin's  cautery  at  a  dull  heat.  If  bleeding  occurs,  do  not 
treat  it  lightly ;  plug  the  vagina,  bringing  the  half  of  the  last  strips  of 
lint  over  the  urethral  orifice  and  fixing  with  a  perineal  band. 

As  regards  the  other  neoplasms,  papillomata  are  painless,  sarcomata, 
very  rare,  their  nature  being  determined  microscopically ;  while  carcino- 


DISEASES  OF  THE  BLADDER.  607 

mata  appear  as  hard  peri-urethral  tubercles  which  break  down  (Skene). 
In  regard  to  treatment,  they  may  be  removed  by  the  curette,  or  by  small 
loop-snares  when  high  up.  Emmet's  button-hole  operation  is  probably 
the  best  method.  Polypi  in  the  urethra  may  cause  great  difficulty  in 
micturition  and  should  be  suspected  in  intractable  cases,  and  examina- 
tion made  by  incision  of  urethra.  We  may  also  have  specific  inflam- 
matory changes  in  Skene's  "  tubules "  (v.  p.  30)  simulating  urethral 
caruncle.  These  may  be  gonorrhoeal,  simple  catarrhal,  or  tubercular. 
The  last  is  usually  found  with  tubercular  disease  elsewhere. 
The  tubules  may  require  to  be  slit  up  and  cauterized. 

URBTHRITI8. 

Acute  urethritis  is  usually  part  of  a  gonorrhoea.  When  pus  is  secreted, 
the  urethra  can  be  felt  swollen  and  tender  ;  the  pus  can  be  squeezed  out 
of  the  urethral  orifice  by  pressure  from  above  downwards ;  on  passage 
of  the  sound,  pain  is  felt  in  the  urethra  although  no  cystitis  be  found. 

Treatment.  Give  diluent  drinks  so  as  to  increase  the  flow  of  urine. 
Copaiba  may  be  given  in  the  form  of  the  well-known  Nesbitt's 
specific : — 

R     Liquoris  Copaibse  Co.  (Nesbitt)  5ij. 

Sig.  Teaspoonful  thrice  daily. 

lodoform  bougies  may  be  passed  in,  and  counter-irritation  applied  in 
the  shape  of  the  tincture  of  iodine  over  the  anterior  vaginal  wall. 

Urethritis  is  very  intractable.  Emmet  advises  his  button-hole 
operation  to  relieve  tension  and  allow  of  accurate  application  of  local 
remedies. 

DILATATION,    AND    STRICTURE    OF   THE    URETHRA. 

The  urethra  may  be  unusually  dilated,  a  condition  rarely  met  with ; 
in  some  cases  the  dilatation  has  been  caused  by  coitus,  as  in  malforma- 
tions of  the  vagina  (v.  p.  260).  The  dilatation  may  be  local  or  general. 
When  it  is  general,  the  cautery  may  be  used  to  burn  a  vertical  furrow, 
the  rest  of  the  urethra  being  guarded  by  a  speculum. 

Stricture  of  the  urethra  is  a  rare  condition  and  readily  yields  to  dilata- 
tion by  bougies  or  to  incision. 

DISEASES   OF   THE   BLADDER,. 

Of  the  diseases  of  the  bladder  we  shall  here  consider  Displacements, 
Neoplasms,  Stone  in  the  Bladder,  and  Cystitis.  Vesico-vaginal  fistula 
will  be  considered  in  a  separate  chapter  (Chap.  LIV.). 

DISPLACEMENTS   OF   THE   BLADDER;   CYSTOCELB. 

The  female  bladder  when  empty  lies  behind  the  pubes  and  usually  to 
one  or  other  side.  It  is  never  exactly  central. 


608    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

The  From  its  loose  attachment  to  the  pubis,  it  is  pre-eminently  displace- 

of°the  able.  (1)  It  is  drawn  up  during  labour;  and  (2)  is  displaced  upwards 
Bladder,  by  retroversion  of  the  gravid  uterus,  pelvic  ovarian  or  fibroid  tumours, 
and  pelvic  haematocele.  (3)  It  may  be  adherent  to  the  anterior  surface 
of  an  abdominal  ovarian  or  fibroid  tumour,  and  may  thus  be  cut  into  on 
abdominal  section.  (4)  It  is  displaced  downwards  in  prolapsus  uteri 
and  in  cystocele.  (5)  In  utero-sacral  cellulitis,  the  bladder  is  drawn 
back  and  fixed  ;  its  systole  is  thus  interfered  with,  which  explains  some 
cases  of  so-called  hysterical  retention  of  urine.  From  this  mobility  it 
follows  that  the  height  of  its  fundus  above  the  symphysis  gives  no 
indication  of  the  amount  of  urine  in  the  bladder. 

By  cystocele  we  understand  a  pouching  of  the  posterior  wall  of  the 
bladder  downwards  and  backwards  ;  the  uterus  and  summit  of  the 
bladder  are  in  normal  position. 

Senile  Many  a  case,  regarded  as  cystocele,  is  really  part  of  a  prolapsus  uteri ; 

Prolapsus   on  ^e  °ther  hand,  the  so-called  "  senile  prolapsus  uteri  "  is  really  a 

cystocele  ;  at  the  menopause  the  cicatrisation  of  the  vaginal  walls  chiefly 

affects  the  posterior  one,  and  thus  the  bladder  tends  to  bulge  outwards 

at  the  vaginal  orifice. 

The  diagnosis  is  easily  made  by  the  Bimanual  and  use  of  the  sound. 
The  treatment  consists  in  the  use  of  a  ring  pessary  with  diaphragm 
(fig.  334).  Should  this  fail,  the  vagina  may  be  packed  with  oakum ; 
or  a  raw  surface  (as  shown  at  fig.  344)  may  be  made  and  stitches 
applied. 

NEOPLASMS    OP    THE   BLADDER. 

Pathological  anatomy.  We  may  have  mucous,  fibroid  or  fibro-myo- 
matous  polypi.  There  may  also  be  sarcomatous  or  carcinomatous  dis- 
ease of  the  bladder  wall,  as  well  as  tubercle.  In  tubercular  disease  the 
ulcerated  surface  has  been  removed  by  Schatz  in  a  supra-pubic  opera- 
tion. The  carcinomatous  condition  is  not  infrequent,  and  is  termed 
by  some  "  villous  cancer."  It  is  most  common  at  the  trigone,  and  is 
held  by  some  authorities  not  to  be  malignant.  The  bladder  may  be 
secondarily  affected  in  carcinoma  uteri  (v.  p.  438). 

Symptoms.  These  are  disturbances  of  micturition,  with  bloody  and 
phosphatic  urine. 

Physical  signs.  The  passage  of  the  index  finger  into  the 
bladder  will  show  the  position,  shape,  and  other  characters  of  the 
growth. 

Treatment.  This  will  vary  according  to  the  position,  nature,  and 
pediculation  or  non-pediculation  of  the  growth.  Thus  it  may  be  twisted 
off  by  narrow  polypus  forceps,  snared  by  a  loop  of  fine  catgut;  or 
removed  by  incision  into  the  posterior  wall  of  the  bladder  and  use  of 
the  galvano-cautery  or  curette. 


DISEASES  OF  THE  BLADDER.  609 

CYSTITIS. 

Nature.  An  acute  or  chronic  inflammatory  affection  of  the  mucous 
membrane  of  the  bladder. 

Pathological  anatomy.  In  the  acute  catarrhal  form,  we  have  conges- 
tion of  the  vessels  and  loss  of  epithelium  ;  in  the  chronic  catarrhal  form, 
the  congestion  is  duller  and  there  is  marked  rugosity  of  the  lining  of  the 
bladder.  The  submucous  and  even  the  muscular  tissues  also  become 
affected.  The  mucous  membrane  may  be  ulcerated  and  the  muscular 
tissue  exposed. 

The  inflammatory  process  may  extend  deeper,  to  the  muscular  tissue 
(interstitial  cystitis),  to  the  peritoneum  (pericystitis),  or  to  the  connec- 
tive tissue  near  (paracystitis).  Occasionally,  though  rarely,  we  may 
have  diphtheritic  inflammation. 

In  advanced  cases,  the  patient  is  usually  septicsemic  and  there  is  often  Results  of 
hydro-nephrosis.     In  some  cases  of  prolonged  retention  the  mucous  Cystltl8' 
membrane  may  slough  off  and  be  passed  per  urethram,  but  may  be 
regenerated. 

Etiology.  The  causes  are  as  follows  : — Gonorrhoea;  latent  gonorrhoea; 
exposure  to  cold ;  injury  from  coitus  ;  prolonged  parturition  ;  introduc- 
tion of  septic  matter  by  catheter  or  bougie ;  prolonged  retention  of 
urine ;  stone. 

Symptoms.  In  acute  cystitis  the  patient  has  very  frequent  and  painful 
micturition.  In  chronic  cystitis  also,  there  is  frequent  micturition  but 
accompanied  with  less  intense  pain ;  there  are,  further,  shooting  pains 
with  secondary  phenomena — septic,  vascular,  and  nervous. 

Physical  signs,  (a)  Acute  cystitis.  The  urine  has  a  lowered  specific 
gravity  and  acid  reaction  ;  the  colour  is  little  altered,  and  mucus  is 
present  in  excess.  On  vaginal  examination,  pain  is  not  felt  when  pres- 
sure is  made  on  the  posterior  vaginal  wall  but  is  felt  severely  when  the 
anterior  ivall  is  touched. 

(b)  Chronic  cystitis.     The  urine  has  a  low  specific  gravity,  is  usually  Characters 
alkaline,  and  is  often  offensive  ;  it  contains  pus,  epithelium,  phosphates  ^^m 
and  bacteria  ;  albumen,  derived  from  the  pus,  is  present.     The  vaginal 
examination  gives  the  same  results  as  in  acute  cystitis.     If  the  finger  be 
passed  through  the  urethra  (v.  p.  600),  the  roughened  condition  of  the 
lining  membrane  is  felt ;  crystals  of  phosphate  and  marked  rugosities 
can  also  be  detected. 

Genito-urinary  phthisis  is  often  diagnosed  as  chronic  cystitis.  In  the 
former  condition  we  get  at  first  the  symptoms  of  chronic  cystitis,  viz., 
purulent  urine,  pain,  and  intractability  to  treatment.  Local  examina- 
tion of  the  bladder  may  give  no  definite  result,  and  if  the  kidney  is  not 
palpated  its  enlargement  and  purulent  condition  may  not  be  noticed 
until  the  disease  is  far  advanced. 
2Q 


610          AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Prognosis.  In  both  acute  and  chronic  cystitis,  the  prognosis  is  not 
good ;  the  treatment  is  difficult,  and  in  bad  chronic  cases  the  patient's 
strength  sometimes  becomes  exhausted  and  septiceemia  may  cause 
death. 

Treatment      Treatment,     (a)  Acute  cystitis.     Put  patient  on  milk  diet,  and  give 
Cystitis?     Friedrichshall  or  Carlsbad  water  freely.     Diluent  drinks  may  be  taken 
ad  libitum. 

The  following  prescription  is  useful. 

R     Potassii  Bicarbonatis  3  iss. 

Tincturse  Hyoscyami  §  i, 

Infusum  Buchu 

vel  Pareirse 

vel  Uvse  Ursi  ad  3  vj. 

Sig.  Tablespoonful  thrice  daily. 

In  gonorrhoeal  cystitis,  the  following  may  be  substituted  : — 

R     Liquoris  Copaibse  Co.  (Nesbitt)  5  ij. 

Sig.  Teaspoonful  thrice  daily. 

Treatment      If  the  pain  is  very  acute  give  morphia  suppositories  (^  grain)  at  night, 
of  Chronic  omitting  the  mixture  with  the  hyoscyamus  if  necessary. 

For  (6.)  Chronic  cystitis,  we  recommend  the  following  treatment 
seriatim. 

1.  Put  on  milk  diet  with  abundant  fluids,  and  purge  freely.     Give 

R     Acidi  Nitrici  diluti  3iij. 

Tincturse  Hyoscyami  gi. 

Infusum  Buchu  ad  §vj. 
Sig.  Tablespoonful  thrice  daily. 

The  hyoscyamus  eases  the  pain ;  and  the  nitric  acid  corrects  the 
alkaline  phosphatic  urine,  for  which  also  benzoate  of  ammonia  is 
admirable. 

R     Ammonii  Benzoatis  3ni. 

Aquae  §  vj. 

Sig.  Tablespoonful  thrice  daily. 

The  benzoate  of  ammonia  is  converted  into  hippuric  acid  and  corrects 
alkalinity.  Lithia  water,  tincture  of  Belladonna,  and  Nesbitt's  specific 
are  also  useful. 

2.  If  this  fail,  then  wash  out  bladder  as  often  as  possible  by  means 
of  double  catheter,  such  as  Skene's  ;  use  corrosive  sublimate  (1-5000  or 
8000),  weak  boracic  lotion,  or  carbolic  lotion  ;  inject  with  the  douche 
or  Higginson's  syringe,  or  use  Foulis'  apparatus.     We  strongly  recom- 


DISEASES  OF  THE  BLADDER.  611 

mend  weak  corrosive  sublimate  as  a  bladder  douche.     Paint  anterior 
vaginal  wall  with  tincture  of  iodine. 

3.  A  long  (winged)  india-rubber  catheter  may  be  kept  in  the  bladder 
so  as  to  drain  off  the  urine  constantly  and  give  the  bladder  rest.     The 
patient  need  not  remain  in  bed  if  the  Skene-Goodman  catheter  (fig.  354) 
is  used, 

4.  In  obstinate  cases,  the  formation  of  an  artificial  vesico-vaginal 
fistula  may  be  tried.     To  do  this,  chloroform  the  patient ;  place  her  in 
the  lithotomy  posture  and  apply  Sims'  speculum.     Open  into  the  bladder 
through  the  anterior  vaginal  wall,  in  the  middle  line,  with  Paquelin's 
cautery  at  a  dull  heat.     This  may  also  be  done  with  the  scissors,  as 
follows  :  pass  the  finger  into  the  bladder,  and  then  by  means  of  a  pair 
of  straight  scissors  cut  it  open  in  the  middle  line.     Preliminary  dilata- 
tion of  the  urethra  with  the  finger  enables  the  operator  with  certainty 
to  avoid  cutting  into  it.     The  advantage  of  the  cautery  is  that  the 
wound  does  not  readily  unite  ;  when  the  opening  is  made  with  knife  or 
scissors,  care  is  required  to  prevent  its  healing.     Emmet  stitches  the 
vesical  and  vaginal  edges  together. 


FIG.  354. 

THE  SKEXE-GOODMAN  SELF-RETAINING  CATHETER  ;  AN  INDIA-RUBBER  BAG  CAN  BE  WORN  WITH  IT 

(««»«)• 

The  urine  trickles  through  the  artificial  fistula;  in  this  way, 
the  bladder  gets  complete  rest  and  can  be  thoroughly  washed 

out. 

After  some  months  the  fistula  is  easily  closed,  as  in  the  operation  for 
vesico-vaginal  fistula.  Severe  cases  of  cystitis  will  tax  more  than  any 
other  disease,  the  practitioner's  patience  and  knowledge.  It  is  well  to 
keep  in  mind  the  reason  of  this  intractability,  viz.,  the  inability  of  the 
bladder  to  remain  at  rest. 

As  can  be  seen  from  what  has  gone  before,  the  principles  of  treatment 
are  the  following  :— (1)  to  correct  abnormalities  in  the  urine ;  (2)  to 
allay  the  irritability  of  the  bladder  ;  (3)  to  lessen  the  congestion  of  the 
bladder  by  purgatives  and  counter-irritants,  and  to  render  the  urine 
bland  and  lessen  the  work  of  the  kidney  by  milk  diet ;  (4)  to  allay  the 
irritable   condition    of   the    bladder   and   counteract    putrefaction    o 
gonorrhceal    inflammation    by    injection;    (5)    to    give    it    comple 
rest  by  a  permanent  catheter   or,  in   extreme  cases,  by  an 
fistula. 


612 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


CALCULI    AND    OTHER    FOREIGN    BODIES    IN    THE    BLADDER. 

The  female  bladder  is  liable  to  receive  foreign  bodies  from  three 
sources. 

A.  Calculi    from    the   kidneys — uric    acid,    oxalates,    phosphates    or 
cystine. 

B.  Substances  from  neighbouring  organs — pus  from  pelvic  abscess, 
concretions  from  the  intestines,  bones  from  an  extra-uterine  foetation, 
pessaries  from  the  vagina,  echinococci  and  other  parasites  such  as  those 
associated  with  chyluria. 

C.  Foreign  bodies  introduced  wilfully  into  the  bladder  by  patients  of 
a  depraved  taste  ;  these  may  form  nuclei  for  stones  (fig.  355). 


Diagnosis 
of  Calculi. 


FIG.  355. 

LARGE  STONE  WHICH  FORMED  ROUND  A  HAIR-PIN  AS  NUCLEUS,  EXTRACTED  BY  VAGINAL  LITHOTOMY 

(Angus  Macdonald). 

Of  these,  calculi  are  the  most  important.  Stone  is  less  common  in  the 
female  than  in  the  male,  as  small  calculi  can  pass  along  the  dilatable 
female  urethra  ;  occasionally,  therefore,  the  gynecologist  has  to  remove 
from  the  urethra  small  stones  impacted  there — usually  at  the  meatus 
urinarius.  The  introduction  of  foreign  bodies,  which  act  as  nuclei,  is 
more  common  in  the  female. 

Symptoms.  These  are  severe  pain  in  micturition,  especially  at  the 
close  ;  alterations  in  character  of  urine  ;  blood  in  urine. 

Physical  signs.     The  stone,  when  at  all  large,  can  be  easily  detected 


DISEASES  OF  THE  BLADDER.  613 

bimanually  ;  when  any  doubt  exists,  the  use  of  the  sound  or  the  passage 
of  the  finger  into  the  bladder  renders  the  diagnosis  easy. 

Treatment.  Measure  the  stone  :  if  it  be  less  than  an  inch,  it  may  be 
extracted  through  the  urethra  dilated  first  by  the  finger  or  Simon's 
specula  ;  if  greater  than  an  inch,  then  dilate  the  urethra  and  crush  ;  if 
very  large  or  hard  or  if  it  have  a  nucleus,  extract  by  vaginal  incision. 
This  incision  may  be  stitched  up  after  the  operation,  or  kept  open  when 
the  bladder  has  been  much  irritated  ;  it  can  afterwards  be  stitched  as  in 
vesico-vaginal  fistula.  Supra-pubic  lithotomy  is  sometimes  required. 

For  other  foreign  bodies,  the  urethra  can  be  dilated  and  the  substance 
grasped  by  polypus  forceps  or  manipulated  out.  When  large,  they  may 
be  extracted  as  in  the  case  of  large  stones. 

FUNCTIONAL   DISEASES    OF   BLADDER. 

By  these  we  understand  derangements  of  the  bladder  in  regard  to  Functional 
.  J    .  TT  i          i  .    •      j          it    affections 

urination.     Either  these  are  due  to  causes  as  yet  unascertained,  or  tne 


same  derangement  (e.g.,  retention)  is  associated  with  many  lesions. 
The  chief  functional  diseases  are  — 

Irritability, 

Incontinence, 

Retention. 

In  regard  to  all  of  them,  we  may  remark  that  in  no  case  should  the 
diagnosis  of  a  functional  disease  of  the  bladder  be  made  until  the  practi- 

O 

tioner  is  satisfied  that  there  is  no  organic  lesion. 

Irritability.  In  this,  frequent  micturition  associated  with  disagreeable 
feeling  is  present.  It  may  be  due  to  excessive  acidity  of  the  urine,  but 
is  often  a  nervous  affection.  When  it  is  due  to  excessive  acidity,  give 
lithia  or  potash. 

R     Lithii  Carbonatis  gr-  v- 

Fiat  pulv.  mitte  tales  vj. 
Sig.  One  thrice  daily. 

Incontinence,  or  inability  to  retain  urine  long  enough,  is  most  common 
in  little  girls  ;  occasionally  we  meet  with  it  in  adults,  as  the  result 
prolonged  labour,  as  a  permanent  condition  from  infancy,  or  in  oxaluru 

In  the  incontinence  of  girls,  note  whether  there  be  any  irritability  of 
the  genitals  (vulvitis)  or  ascarides.     Goltz  found  that,  where 
the  spine  in  the  dog  above  the  lumbar  enlargement  had  producec 
tion  of  urine,  he  could  make  it  urinate  by  sponging  the  anus  with  co 
water  ;  a  reflex  impulse  passed  from  the  rectum,  lessening  tl 
of  the  inhibitory  centre  and  allowing  bladder  contraction. 
ascarides  in  the  rectum  will  act  in  the  same  way  when  it  is  asleep. 


614    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Treatment.  Treat  the  irritating  cause — as  vulvitis  or  ascarides.  If 
no  irritating  cause  be  detected,  then  give  belladonna. 

R     Tincturse  Belladonnas  3ij- 

Sig.  Three  drops  thrice  daily. 

In  strumous  cases,  give  syrup  of  the  iodide  of  iron  or  cod  liver  oil. 

R     Syrupi  Ferri  lodidi  ^ij. 

Sig.  Thirty  drops  thrice  daily. 

Retention  of  Urine.  Palpation  shows  a  fluctuating  mesial  tumour 
rising  into  the  abdomen ;  the  position  of  the  fundus  of  the  bladder  gives 
no  indication  of  the  amount  of  urine,  as  it  may  be  tilted  up  by  retrover- 
sion  of  the  gravid  uterus.  Remember  that  a  bladder  may  be  dis- 
tended so  as  to  be  as  large  as  a  six  or  eight  months'  pregnancy,  and  that 
constant  dribbling-away  of  the  urine  may  be  a  symptom  of  retention. 
Examine  the  pelvis  for  an  organic  lesion. 

Retention  may  be  due  to  one  of  three  great  classes  of  causes  : — 

Hysterical, 

Reflex, 

Mechanical. 

1.  Hysterical.     By  this  we  mean  that  from  perversity  or  a  prurient 
desire  to  have  the  catheter  passed,  a  patient  feigns  inability  to  pass 
urine. 

The  treatment  is  to  give  a  hot  hip  bath  followed  by  a  cold  one ;  if 
the  catheter  is  needed,  get  it  passed  by  a  nurse  of  unsympathetic 
tendencies. 

2.  Reflex  causes  are  the  following  : — 

(1)  Gonorrhoea; 

(2)  Urethritis; 

(3)  Irritable  caruncle ; 

(4)  Carcinoma,  urethral  and  vaginal ; 

(5)  Perineal  and  especially  vestibular  tears  after  labour,  tears  of 

cervix ; 

(6)  Ligature  of  internal  piles. 

The  treatment  is  hot  appliances  in  (1),  (2),  (3),  and  (5)  and  (6);  and 
the  catheter  in  (4).  Remove  the  source  of  irritation  when  possible. 

3.  Mechanical.      These  are  pressure  of  fibroids,  retroversion  of  the 
gravid   uterus ;     ovarian    or    parovarian   tumours    (pelvic   and   retro - 
uterine). 

Where  the  tumour  is  impacted  in  the  pelvis,  a  silver  male  (No.  10) 
catheter  will  pass  best.  The  urethra  is  compressed,  the  bladder  bulging 
over  the  symphysis ;  accordingly,  a  rigid  instrument  whose  handle  can 
be  carried  to  the  perineum  is  good. 


CHAPTER   LIV. 

VESICO-VAGINAL    FISTULA. 

LITERA  TURE. 

Baker  Brown — Surg.  Diseases  of  Women,  3d  Ed.,  p.  133;  and  Lancet,  March  1864. 
Bandl— Wiener  Med.  Woch.,  1875,  Nos.  49  to  52 ;  and  1877,  Nos.  30  to  32.  Bozc- 
man — Remarks  on  Vesico- vaginal  Fistula,  1856 ;  Americ.  Journ.  of  Med.  Science, 
July  1870;  Obst.  Journ.  of  Great  Britain,  June  to  Aug.  1878.  By  ford — Medical 
and  Surgical  Diseases  of  Women  :  Philadelphia,  1882.  Emmet — On  Vesico-vaginal 
Fistula  :  New  York,  1868.  Hcgar  und  Kaltcribach — Die  Operative  Gynakologie,  S. 
582  :  Stuttgart,  1881.  Simpson,  Sir  J.  Y.—  Diseases  of  Women,  p.  30  :  Edin.  1872. 
Sims,  Marion — On  the  Treatment  of  Vesico-vaginal  Fistula  :  Americ.  Jour,  of  Med. 
Science,  Jan.  1852.  Silver  Sutures  in  Surgery  :  New  York,  1858.  Simon — Ueber 
die  Heilung  der  Blasenscheidenfisteln ;  Giessen  1845,  Rostock  1862,  and  Wiener 
med.  Wochenschrift,  1876,  Nos.  27-32.  Winckel—  Die  Krankheiten  der  weiblichen 
Harnrohre  u.  Blase  :  Stuttgart,  1877,  S.  95.  For  recent  literature,  see  Index  in 
Appendix. 

PATHOLOGICAL    ANATOMY   AND    VARIETIES. 

THE  septum  between  the  urinary  and  genital  tracts  may  be  broken 
through  at  various  points.  According  to  their  situation,  we  have  the 
following  varieties  of  urinary  fistulse  : — 

Urethro- vaginal, 

Vesico-vaginal, 

Vesico-uterine, 

Uretero-vaginal, 

Uretero-uterine. 

The  situation  of  these  is  sufficiently  indicated  by  their  names,  and 
will  be  easily  understood  by  reference  to  fig.  356. 

A  urethro-vaginal  fistula  rarely  occurs  alone,  but  is  sometimes  present 
along  with  a  vesico-vaginal  one.  It  lies  in  the  middle  line  and  is, 
naturally,  of  smaller  size. 

By  far  the  most  frequent  are  the  vesico-vaginal  fistula}.     They 
occur  at  any  point  of  the  vesico-vaginal  septum,  which  measures 
height  (from  the  internal  orifice  of  the  urethra  to  the  vaginal  fornix)* 
about  5  cm.  and  in  breadth  4  cm.  (Kafonbach).     Their  size  varies  from 
a  pin-point  or  slit-like  hole  to  a  large  oval  (fig.  361)  or  four-cornered 
(fig.  383)  aperture.      When  recent  they  are   of  larger  size,  but  after 
some  months  become  contracted  through  the  formation  of  cicatncial 


616 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


tissue.     The  margins  of  the  fistula  are  at  first  irregular,  swollen,  and 
ulcerated ;  but  after  a  time  they  become  thin  and  firm,  through  cicatri- 


FIG.  356. 

TO   REPRESENT  THE   CHIEF   VARIETIES    OF    URINARY   FlSTULA — URETHRO-VAGINAL,    VESICO-VAGINAL, 

AND  VESICO-UTERINE.     Those  with  the  ureters  are  not  seen.     The  seat  of  a  recto- vaginal  fistula 
is  indicated  (De  Sinety). 

sation  :  these  changes  have  an  important  bearing  on  treatment.    Jobert 
divided  fistulse  in  the  anterior  fornix  into  superficial  and  deep;  in  the 


FIG.  357. 


FIG.  358. 


SUPERFICIAL  VESICO- VAGINAL  FISTULA,  the       DEEP  VESICO-VAGINAL  FISTULA,  the  anterior  lip 
Cervix  is  intact  (Hegar  and  Kaltenbach).  of  the  Cervix  is  destroyed  (//.  and  K). 

former  (fig.  357)  the  anterior  lip  of  the  cervix  was  not  implicated,  in  the 
latter  it  was  more  or  less  destroyed  (fig.  358).    In  cases  of  fistulse  which 


VESICO-  VA  GINAL  FISTULA . 


617 


allow  a  free  flow  of  urine,  the  bladder  becomes  permanently  contracted 
and  its  walls  thickened ;  in  large  fistulse,  the  mucous  membrane  pro- 
trudes through  the  opening  and  is  easily  recognised  from  its  deep  red 
colour.  The  normal  relation  of  the  openings  of  the  ureters  to  that  of 
the  urethra  and  to  the  cervix  uteri  (fig.  359)  renders  them  liable  to  be 
involved  in  an  extensive  fistula,  or  even  in  a  small  one  lying  to  one  side 
of  the  middle  line.  Sometimes  we  can  recognise  their  openings  on  the 
exposed  vesical  mucous  membrane  by  means  of  the  urine  trickling  from 
the  orifices ;  should  the  urine  be  bloodstained,  it  can  be  distinguished 
from  blood  by  its  acid  reaction  to  test  paper.  The  urethra,  through 
disuse,  becomes  contracted ;  sometimes  complete  atresia  is  present  and 
seriously  complicates  treatment,  and  a  portion  of  the  canal  may  even  be 
completely  destroyed  by  pressure  (v.  fig.  388).  The  vagina  is  often  con- 
tracted by  cicatricial  tissue  originating  from  injuries  received  during 
labour.  The  margins  of  the  fistula  are  often  drawn  apart,  and  some- 


3.CM 


FIG.  359. 

THE  NORMAL  RELATION  or  THE  CERVIX,  THE  UKETERS ,  AND  THE  URETHRA  (Iff.  and IK.)  From 
cervix  to  orifice  of  ureter  measures  3  cm.,  from  orifice  of  ureter  to  that  of  urethra  ™»™™ 
4  cm.,  from  orifice  of  one  ureter  to  that  of  the  other  measures  2 -5  to  3  'g-.**™**™ 
through  the  bladder  wall  in  an  oblique  direction  downwards  and  inwards,  for  from 

times  fixed  down  to  the  bone,  by  these  cicatrices;  this  interferes  with 
their  closure.     Contraction  of  the  vagina  below  the  fistula  sometimes 
makes  it  impossible  to  ascertain  the  condition  of  the  upper  pai 
whether  the  uterus  communicates  with  the  fistulous  tract, 
tions  of  the  peritoneum  to  fistula  are  shown  in  fig.  360,  from  which  it  is 
evident  that  only  in  the  repair  of  very  extensive  fistula  would  . 
tions  require  to  be  considered.     The  difficult  labour  which  leads 
production  of  the  fistula  is  liable  to  be  followed  by  puerperal  per 
tonitis  or  cellulitis;    these   may  disturb   the  normal  rel 
peritoneum.  v  a 

Vesico-uterine  fistula)  are  rare.      From  their  position  they  can  b 


618 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


Mode  of 
production 
of  Fistula 
in  Labour. 


recognised  only  after  dilatation  of  the  cervical  canal  (v.  fig.  387),  and  it 
is  evident  that  they  must  be  very  small. 

Uretero-vaginal  fistulse  are  situated  in  the  fornix  vaginae.  They  are 
of  small  size,  admitting  only  the  point  of  the  sound,  and  have  either 
sharp  edges  or  open  at  the  point  of  a  small  papilla. 

Josephson1  cites  twenty-three  cases,  and  finds  that  it  has  arisen  from 
injury  in  labour  (when  the  ureter  has  been  fixed  to  the  uterus), 
from  association  with  a  vesico-vaginal  one,  from  operations  on  cervij 
and  excision  of  uterus,  and  has  also  been  congenital  (four  cases). 

Of  uretero-uterine  fistula,  twelve  cases  were  collected  by  him. 

ETIOLOGY. 

Malignant  disease  is  the  most  common  cause  of  fistula  (v.  p.  466) 
but  we  place  this  form  aside,  as  it  is  beyond  treatment  and  merely 
indicates  a  stage  in  the  progress  of  the  malignant  growth. 

The  most  important  cases  of  fistulse  which  we  have  to  consider  here 


FIG.  3GO. 

RELATIONS  OF  PERITONEUM,  indicated  by  dotted  line,  to  a  fistula  which  has  destroyed  the  whole  of 
the  anterior  wall  of  the  cervix  and  the  infra-vaginal  part  of  the  posterior  wall  (H.  and  K.) 

arise  through  injury   received  during   labour.       This    injury   may   act 
directly,  producing  laceration  of  the  septum;  more  frequently  it  act 
indirectly,  producing   necrosis  secondary  to  pressure   or  inflammatior 
The  causes  which  predispose  to  fistula  are  a  narrow  pelvis  and  pendu- 
lous abdomen,  a  firm  or  large  head  (hydrocephalus),  and  face  present 
tions  (Wincket).     The  immediate  cause  is  the  compression  of  the  sof 
parts  between  the  child's  head  and  the  bony  wall  of  the  pelvis  ;  if  this 
pressure  continues  for  a  long  enough  time,  it  destroys  the  vitality  of 
the  soft  parts  which  afterwards  separate  as  a  slough. 

Fistulse  produced  by  instruments  are  situated  in  the  lower  part  of  the 
vagina,  and  are  accompanied  with  extensive  cicatrices  and  adhesions ; 
those  due  to  pressure  of  the  foetal  head  are  placed  in  the  upper  part 
( Winckel).  In  craniotomy,  the  soft  parts  have  been  sometimes  lacerated 

1  Lancet,  1887,  p.  496. 


VESICO-VAGINAL  FISTULA.  619 

by  the  instruments,  or  by  splinters  of  foetal  bone.  Forceps  are  often 
cited  as  a  cause  of  the  injury.  It  is  not  however  the  use  of  the  forceps 
after  a  prolonged  labour  which  is  to  blame,  but  the  not  using  of  them  at 
an  early  period — before  the  parts  have  been  destroyed  by  pressure. 

Fistulee  have  followed  diphtheritic  inflammation  in  the  puerperium, 
but  this  is  rare.  Inflammation  and  ulceration  round  badly  fitting 
pessaries  have  also  produced  them. 

SYMPTOMS. 

The  leading  symptom  is  the  involuntary  flow  of  urine  from  the  vaginal 
orifice.  1'his  will  not  appear  until  the  slough  separates,  that  is  till  about 
the  third  or  fourth  day  ;  its  separation  may  be  delayed  for  three  or  four 
weeks,  when  the  necrosis  is  secondary  to  puerperal  vaginitis  (Byford). 
When  a  direct  laceration  has  been  produced,  the  urine  will  flow  at  once 
per  vaginam;  but  even  here  it  may  escape  notice' till  the  second  or 
third  day,  as  it  is  masked  by  the  lochial  discharge. 

The  power  of  retaining  varies,  in  certain  cases,  with  the  position  of 
the  patient ;  with  a  fistula  situated  high  up,  the  erect  posture  allows 
the  lower  portion  of  the  bladder  to  be  used  though  the  flow  is  continuous 
in  the  recumbent  posture.  With  a  urethro-vaginal  fistula,  there  may 
be  perfect  continence  from  a  sphincter-like  action  of  the  muscular  fibre 
in  the  wall  of  the  urethra  ;  the  patient  observes,  however,  that  the  urine 
does  not  pass  by  the  urethral  orifice. 

Secondary  symptoms  are  due  to  a  constant  wetting  of  all  the  sur- 
rounding parts  with  the  urine.  The  urinous  odour  is  quite  character- 
istic in  urinary  fistula ;  there  is  excoriation  round  the  vulva,  the  inside 
of  the  thigh  is  red  and  irritated.  Menstruation  is  generally  in  abey- 
ance, returning  after  the  fistula  has  been  cured.  There  is  usually 
sterility;  although  cases  of  conception,  often  followed  by  abortion  or 
premature  labour,  have  been  recorded.  The  disagreeable  surroundings 
interfere  with  the  appetite  and  digestion ;  there  is  constipation,  which 
Freund  has  ascribed  to  increased  secretion  by  the  kidneys  but  which  is 
more  probably  due  to  reflex  contraction  of  the  muscular  fibre  of  the 
rectum  ( Winckel).  The  general  health  thus  becomes  seriously  impaired 
so  that  the  patient  is  willing  to  submit  to  any  operation  which  promises 
relief. 

DIAGNOSIS. 

The  irritated  appearance  of  the  external  genitals  with  the  character- 
istic odour  at  once  indicates  that  there  is  fistula,  but  the  diagnosis  of 
its  position  is  often  very  difficult. 

Urethro-vaginal  and  vesico-vaginal.       When  large,  these  may  be  f 
by  the  examining  finger  •  on  our  passing  the  sound  into  the  bladder 
finger   touches    it   through   the   fistula.      The   speculum   shows 
position  and  extent,  and  reveals  smaller  ones  which  escape  detects 


620          AFFECTIONS  OF  BLADDER  AND  RECTUM. 

with  the  finger ;  by  stretching  the  folds  of  the  mucous  membrane  with  ] 
tenacula,  we  may  detect  a  fistula  concealed  by  them. 

To  recognise  small  vesico-vaginal  fistula)  and  to  differentiate  them 
from  the  vesico-uterine  and  ureteric,  proceed  as  follows : — pass  Sims' 
speculum,  carefully  wipe  away  all  mucus  from  the  anterior  vaginal 
wall,  clear  out  the  cervical  canal  with  a  dressed  sound  and  plug  it  with 
a  pledget  of  dry  cotton  wadding ;  now  pass  a  catheter,  and  through  it  '._ 
distend  the  bladder  slowly  with  a  coloured  fluid  such  as  milk  or  per- 
manganate of  potash ;  as  the  bladder  distends,  watch  carefully  the 
anterior  vaginal  wall  for  any  oozing  of  the  fluid.  If  there  is  no  oozing, 
the  fistula  is  not  vesico-vaginal.  If  on  withdrawing  the  plug  from  the 
cervix  it  be  found  stained  with  fluid,  the  fistula  is  vesico-uterine.  If 
neither  of  these  forms  be  present,  the  urine  must  come  from  a  ureteric 
fistula ;  the  rarity  of  this  form  should  lead  us  to  suspect  that  the  fluid 
may  have  been  temporarily  kept  from  escaping  from  the  bladder  by  a 
valvular  action  of  the  mucous  membrane,  and  the  examination  should 
be  repeated  after  a  time.  In  a  case  of  uretero-uterine  fistula,  Berard 
collected  the  urine  which  escaped  per  vaginam  in  one  vessel  and  that  in 
the  bladder  was  drawn  off  per  urethram  by  a  catheter  into  another ;  the 
quantities  in  a  given  time  were  found  to  be  equal.  His  conclusion  was 
that  he  had  obtained  the  secretions  from  each  kidney  separately,  so  that 
the  fistula  was  xireteric. 

PROGNOSIS. 

A  natural  cure  will  depend  on  the  recentness  of  the  fistula  and  its 
size.  Small  fistulee,  if  kept  clean,  heal  of  themselves  during  the  puer- 
perium.  Large  ones  require  operative  treatment;  cure  by  this  means 
depends  partly  on  the  size  of  the  fistula,  but  more  on  the  condition  of 
its  margins — whether  they  contain  much  cicatricial  tissue,  and  whether 
they  are  bound  down. 

TREATMENT. 

There  are  two  essentials  for  successful  operative  treatment:  (1)  com- 
plete exposure  of  the  fistula,  so  that  (2)  the  edges  may  be  thoroughly 
pared  and  carefully  adapted  with  sutures.  The  great  difficulty  lies  in 
the  inaccessibility  of  the  field  of  operation,  to  which  the  failure  of  the 
older  operative  measures  is  chiefly  to  be  attributed. 

Marion  Sims  (1849)  first  rendered  successful  treatment  really  possible 
by  the  complete  exposure  of  the  fistula  with  his  speculum,  and  by  the 
careful  adaptation  of  its  margins  with  silver-wire  sutures.  Since  the 
introduction  of  catgut,  we  believe  that  it  will  displace  silver  wire  in 
this  operation  as  it  does  not  need  to  be  removed  subsequently.  To 
Simon  of  Heidelberg  is  due  the  credit  of  having  elaborated  the  operation, 
and  of  having  extended  its  sphere  so  that  almost  no  form  of  fistula  has 
in  his  hands  proved  incapable  of  treatment.  We  may  shortly  contrast 


VESICO-VAGINAL  FISTULA.  621 

the  methods  of  these  two  leading  operators  as  follows :  Sims  pares  the 
edges  of  the  fistula  in  a  sloping  manner  (fig.  363)  carefully  avoiding  the 
mucous  membrane  of  the  bladder,  then  adapts  the  margins  of  the  fistula 
with  silver  wire,  and  drains  the  urine  continuously  per  urethram 
through  a  catheter;  Simon  pares  away  the  edges  vertically  not  specially 
avoiding  the  mucous  membrane  of  the  bladder,  unites  the  edges  with 


FIG.  361. 

METHOD  OF  PARING  THE  EDGES  OF  A  FISTULA  (Simon). 

silk  sutures,  and  encourages  the  patient  to  pass  water  unaided  from  the 
first— drawing  it  off  with  the  catheter  only  when  necessary.  Bozeman, 
a  pupil  of  Sims,  has  drawn  attention  to  the  advantages  of  the  genu- 
pectoral  posture  in  operating  and  to  the  importance  of  preparatory 


622    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

treatment  by  dividing  and  stretching  cicatricial  contractions ;  he  fixes 
the  sutures  Avith  lateral  plates  and  buttons. 


FIG.  362. 

SUTURES  PASSED  IN  A  CASE  OF  URINARY  FISTULA  (Simon). 


FIG.  363. 

THE  AMERICAN  AND  GERMAN  METHODS  OF  PARING  THE  EDGES  OF  FISTULA  CONTRASTED  ;  Sims'  is 
shown  on  the  right,  Simon's  on  the  left.  The  mucous  membrane  of  the  bladder  is  above,  that 
of  the  vagina  is  below.  The  edges  may  be  pared  first  according  to  Sims'  method,  and  if  a  raw 
surface  is  not  thus  obtained  the  tissue  can  be  removed  up  to  the  fine  line  (Kcdtenltach). 

When  a  fistula  has  been  discovered  during  the  puerperium,  our  first 


VESICO-VAGINAL  FISTULA.  623 

aim  is  to  aid  the  natural  effort  at  cure.  A  catheter  (fig.  389)  is  placed 
in  the  urethra  to  carry  off  the  urine  by  the  natural  passage  ;  the  vagina 
is  syringed  out  frequently  with  warm  water ;  the  edges  of  the  fistula 
may  be  kept  together,  in  some  cases,  by  tampons  suitably  placed  in  the 
vagina. 

If  the  fistula  does  not  close  by  the  natural  process,  we  have  recourse 
to  operation. 

Operation  for   Vesico-vaginal  Fistula. 

There  is  difference  of  opinion  as  to  the  time  for  operating.  According 
to  Hegar  and  Kaltenbach,  the  best  time  is  six  to  eight  weeks  after  the 
confinement ;  "  the  lochial  discharge  has  ceased,  the  necrosis  of  the 
tissues  is  defined,  the  margins  of  the  fistula  are  vascular  and  juicy  and 
are  at  the  same  time  of  sufficient  firmness  to  hold  the  sutures;"  the 
cicatricial  tissue  which  forms  round  the  margins  makes  the  operation 
more  difficult  afterwards.  Marion  Sims  delays  the  operation  for  a  few 
months. 

Under  the  operation,  we  shall  describe — 

1.  Preparatory  treatment ; 

2.  The  operation,  which  consists  of  (a)  the  paring  of  the  edges 

of  the  fistula  and  (6)  their  adaptation  with  sutures ; 

3.  After-treatment. 

1.  Preparatory  treatment  is  only  necessary  when  there  are  cicatricial 
bands  drawing  the  margins  of  the  fistula  apart  or  contracting  the  field 
of  operation.     These  must  be  divided  and  made  to  heal  over  a  glass  plug, 
or  the  vagina  must  be  kept  distended  with  air-bags.     Frequent  vaginal 
injections  are  necessary  in  all  cases,  to  bring  the  edges  into  as  good 
condition  as  is  possible. 

2.  For  the  operation  itself  the  following  instruments  are  required 

Sims'  speculum, 
Spatulse, 

Three  or  four  tenacula, 
Blunt-hook, 

Vaginal  douche  for  permanent  irrigation, 
Hot  water  to  check  haemorrhage, ' 
Dissecting  and  artery  forceps, 

Small  bistouries  straight  or  set  at  an  angle— on  long  handles, 
Bozeman's  scissors, 

Several  small  sponges  and  sponge-holders, 
Short  curved  needles  and  needle-holder, 
Curved  needles  on  fixed  handles, 
Silver  wire  and  wire  twister,  or  Catgut. 
Good  light  is  essential  and  as  complete  exposure  of  the  field  of  opera- 


624 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


tion  as  is  possible ;  this  last  will  determine  the  position  of  the  patient, 
according  as  Sims'  or  the  lithotomy  posture  allows  us  to  get  more  readily 
at  the  fistula.  The  drawing  down  of  the  cervix  with  volsellse  or  sutures 
(fig.  361),  or  the  protrusion  of  the  edges  of  the  fistula  by  a  catheter  ii 
the  bladder,  is  of  use  in  some  cases  ;  where  the  mucous  membrane  of  the 
bladder  (by  prolapsing  through  the  fistula)  comes  in  the  way,  it  can  b« 
kept  back  by  the  sound  in  the  bladder  or  a  sponge  probang  pushe 
through  the  fistula  (Sir  J.  Y.  Simpson). 


FIG.  364. 


FIG.  365. 


FIG.  366. 

KNIVES  FOR  PARING  A  FISTULA.     Fig.  364,  straight  knife ;  fig.  365,  bent  knife  wh 
laterally  at  fig  366  (Sir  J.  Y.  Simpson). 


ich  i 


Chloroform  is  always  an  advantage,  as  it  gives  the  operator  more 
freedom  in  exposing  the  parts  and  prevents  the  patient  from  moving ; 
the  actual  pain  of  the  operation  does  not  demand  it. 

Three  assistants  are  needed — one  to  give  chloroform,  a  second  to 
hold  the  speculum,  a  third  for  the  sponges ;  six  are  better,  as  two  are 
required  with  the  patient  in  the  lithotomy  posture  and  there  is  one  to 


FIG.  367. 
SPONGE-HOLDER. 

take  charge  of  the  instruments.  The  knives  employed  are  shown  at  figs. 
364-66.  The  sponges  should  be  very  small  and  fitted  on  holders  of 
which  a  convenient  form  is  shown  at  fig.  367.  Fixed  needles  are 
required  when  the  tissue  is  dense.  Sir  J.  Y.  Simpson  used  a  tubular 
needle  such  as  that  seen  at  fig.  368,  which  is  sometimes  of  service. 

(a.)  The  paring  of  the  edges  of  the  fistula.  To  produce  union,  it  is 
essential  to  have  a  continuous  raw  surface  all  round  the  margin.  To 
procure  this,  we  hook  up  with  a  tenaculum  the  portion  of  vaginal  mucous 
membrane  to  be  removed  and  transfix  it  with  the  knife  (v.  fig.  361  and 


VESICO-  VA  G1NAL  FISTULA . 


625 


FIG.  369. 

PASSAGE  or  THE  THREAD  WITH  THE  TUBULAR 
NEEDLE  (Sir  J.  Y.  Simpson), 


FIG.  368. 

STAKTIN'S  TUBULAR  NEEDLE'FOR  VESICO-VAGIKAL 
FISTULA  (Sir  J.  Y.  Simpson). 

2R 


626 


AFFECTIONS  OF  BLADDER  AXD  RECTUM. 


fig.  370).  The  knife  should  not  pass  through  the  mucous  membrane  of 
the  bladder,  unless  there  be  so  much  cicatricial  tissue  that  a  large  piece 
requires  to  be  cut  out ;  the  reason  for  avoiding  the  vesical  mucous  mem- 
brane is  to  prevent  after-heemorrhage  into  the  bladder.  In  small  fistulse, 
we  can  remove  the  tissue  in  a  ring  and  thus  ensure  a  continuous  raw 


FIG.  370. 

TRANSFIXING  WITH  A  KNIFE  BOTH  EDGES  OF  THE 
FISTULA  AT  ONCE  (Sir  J.  Y.  Simpson). 


FIG.  371. 

FISTULA  SHOWN  AT  FIGS.  369  AND  370  CLOSED 
WITH  SUTUKES  (Sir  J.  Y.  Simpson). 


surface ;  in  larger  fistulse,  we  may  take  flaps  from  the  adjoining  vaginal 
wall.1 

Another  method  of  making  a  raw  surface  is  to  split  up  the  edges  so 
that  the  vesical  mucous  membrane  is  separated  from  that  of  the  vagina ; 


FIG.  372. 

BOZEMAN'S  FORK,  used  in  drawing  through  the  wires  to  prevent  their  cutting  the  Vaginal 
Mucous  Membrane  (Sir  /.  Y.  Simpson). 

the  advantage  of  this  method  is  that  no  tissue  is  lost,  but  the  stitching 
is  less  accurate. 

Haemorrhage  is  best  checked  by  hot  douche ;  large  bleeding  points 
may  require  twisting  or  even  ligature. 

1  As  W.  Duncan  has  done  successfully — Brit.  Med.  Journ.  1SS7,  II.,  p.  936. 


VESICO-  VA  GINAL   FISTULA . 


627 


(6.)  The  adaptation  of  the  edges  with  sutures  must  be  carefully  done.  Passage  of 
If  of  catgut  the  sutures  may  be  passed  on  an  ordinary  curved  needle ;  u 
if  of  wire,  then  a  fixed  needle  (which  is  made  to  transfix  both  margins 
of  the  fistula  and  then  threaded),  or  a  hollow  needle  (fig.  368)  may  be 
necessary.     To  prevent  the  sutures  from  cutting  the  vaginal  mucous 
membrane  as  they  are  drawn  through,  the  fork  or  pulley  (figs.  372,  373) 


FIG.  373. 
METHOD  OF  USING  FORK  (Emmet). 

can  be  used.     The  sutures  must  be  pretty  close  together  and  should 
either  not  pierce  the  vesical  mucous  membrane  or  should  take  in  only 
its  margin.     When  the  tissues  are  dense,  counter  pressure  against  the  Counter- 
point of  the  needle  may  be  made  with  a  blunt  hook  as  in  fig.  374. 
Sims  passes  a  silk  thread  first  and  then  uses  it  to  draw  through  the  tissue, 
wire  suture. 

After  all  the  sutures  are  passed,  they  are   tied  (fig.  376)  or  twisted 


FIG.  374. 

MODE  OF  APPLYING  COUNTER-PRESSURE  TO  THE  POINT  or  THE  NEEDLE  BY  MEANS  or  A  BLTOT 

HOOK  (Emmet). 

(figs.  375,  379) ;  to  bring  the  wires  together  we  can  use  Bozeman's 
suture-adjuster  (fig.  377) ;  the  wire  twister  (devised  by  Coghill)  is  very 
convenient  for  twisting  the  wires  close,  especially  when  the  fistula 


628    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Bozeman's  is  deeply  placed  and  not  very  accessible  (fig.  378).     Bozeman  uses  a 
method. 


FIG.  375. 
SIMS'  METHOD  or  FIXING  AND  TWISTING  THE  SUTURES  (after  Sims).. 


FIG.  376. 
MODE  OF  TYING  SILVER-WIRE  SUTURES  (Sir  J.  Y.  Simpson). 

plate  to  fix  the  sutures.     The  use  of  catgut  does  away  with  all  these- 


VESICO-VAGINAL  FISTULA.  629 

appliances.     The  fistula  seen  at  fig.  369  is  shown,  after  the  sutures 


FIG.  377. 

BOZSMAS'S  SUTURE-ADJUSTEK  (Sir  J.  Y.  Simpson). 


FIG.  378. 


FIG.  379. 

COGHILL'S  WIRE  TWISTER,  fig.  378  ;  its  point  threaded  with  a  wire  is  shown  at  fig.  379 
(Sir  /.  Y.  Simpgon). 


FIG.  381. 

WIRES  DRAWN  THROUGH  BozEMAu's  PLATE,  fig.  380  ;  fixed  with  shot  as  in  fig.  3S1 
(Sir  /.  Y.  Simpson). 


FIG.  382. 
SPECULUM  PASSED  FOR  REMOVAL  or  SUTURES  ;  the  patient  is  on  her  side  (Sir  /.  Y.  Simpson). 

have  been  twisted  up,  at  fig.  371.     With  a  triangular  fistula  the  closed 


630  AFFECTIONS  OF  BLADDER  AND  RECTUM. 

wound  will  be   Y-shaped,  while   a  quadrilateral   fistula  will   give   an 
I-shaped  wound  (figs.  383,  384). 


FIG.  383.  FIG.  384. 

FOUR-CORNERED  FISTULA,  tig.  383,  closed  by  Sutures  in  fig.  384  (Hegar  and  Kaltenbach). 


FIG.  385. 

SUTURES  PASSED  THROUGH  ANTERIOR  LIP  or  CERVIX  so  AS  TO  CLOSE  IN  TRANSVERSELY  A  FISTULA 
OF  THE  ANTERIOR  FORNIX  (If.  and  K.). 

In  the  case  of  fistulse  situated  close  to  the  cervix,  we  make  use  of  the 
cervix.       anterior  lip  to  close  the  fistula ;  the  result  is  a  crescentic  wound  (fig. 


VESICO-VAGINAL  FISTULA.  631 

385).     Sometimes  we  have  to  excise  a  portion  of  the  cervix  to  get  a 


FIG.  CSG. 

ANTERIOR  LIP  DIVIDED  TO  CLOSE  IN  VERTICALLY  A  FISTULA  CLOSE  TO  IT  :  a  6  c  shows  extent  of 
surface,  round  the  oval  fistulous  opening,  to  be  made  raw ;  the  mucous  membrane  may  have 
to  be  incised  outside  the  sutures,  along  the  line  A  B,  to  relieve  tension  (Emmet). 


FIG.  387. 

VESICO-UTERINE  FISTULA.     The  lips  of  the  cervix  are  pared,  preparatory  to  stitching  up  the  cervical 

canal  (H.  and  K.). 

sufficient  raw  surface  (fig.  386).     When  much  of  the  anterior  lip  is 


632 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


destroyed,  it  may  be  necessary  to  use  the  posterior  lip  to  close  the  fistula 
(see  fig.  358,  and  compare  it  with  fig.  357) ;  in  this  case  the  uterus  will 
communicate  with  the  bladder  and  the  menstrual  blood  be  discharged 
per  urethram.  With  vesico-uterine  fistulee,  two  courses  are  open.  If 
possible,  we  expose  the  fistula  by  splitting  the  cervix  bilaterally1  and 
treat  it  as  vesico-vaginal  fistula :  when  this  cannot  be  done,  we  pare  the 
edges  of  the  os  and  stitch  up  the  cervical  canal ;  we  thus  make  the 
uterus  open  into  the  bladder  (fig.  387). 


FIG.  388. 

VESICAL  FisTULA+Atresia  of  a  portion  of  the  urethra  ur  just  below  the  symphysis  «.     The  latter  is 
first  bridged  over  at  1  and  then  the  vesical  fistula  closed  in  at  2  (  Winded). 


After- 
Treatment. 


When  there  is  a  urethral  as  well  as  a  vesical  fistula,  the  former  must 
be  closed  first  :  when  there  is  atresia  of  the  urethra,  the  free  margins  of 
the  urethral  wall  above  and  below  are  pared  and  united  by  sutures  so  as 
to  bridge  over  the  atresic  portion  (fig.  388)  ;  the  vesical  fistula  is 
obliterated  by  a  second  operation. 

3.  After-treatment.  A  stationary  catheter  is  placed  in  the  bladder. 
The  form  in  fig.  389  is  the  one  generally  used,  the  urine  being  made  to 
drip  into  a  long  narrow  vessel  (as  a  soap-dish)  passed  between  the 


FIG.  389. 


FIG.  390. 


SIMS'  STATIONARY  CATHETER  :  fig.  389,  first  model  ;  fig.  390,  newest  model.  That  in  fig.  389  is 
made  of  block  tin  so  that  it  can  be  bent  to  any  curve  ;  when  in  situ,  it  must  be  bent  so  that  the 
external  end  has  its  groove  uppermost  :  that  in  fig.  390  is  of  rubber  and  has  tubing  attached 
to  it. 

patient's  thighs  ;  two  catheters  are  required,  so  that  they  may  be 
changed  every  day  as  the  salts  of  the  urine  readily  occlude  the  tube  ; 
the  one  not  in  use  should  be  kept  thoroughly  clean. 

>  Sanger  (Centralb.  f.  Gyn.,  XII.,  8.  377)  makes  one  of  the  splits  extend  into  and  above  the 
fistula,  so  that  the  closure  of  the  split  closes  the  fistula  also  ;  the  sutures  are  all  tied  outside  the 
cervix  as  in  Emmet's  operation. 

Champneys  (Brit.  Med.  Journ.,  1888,  II.,  818)  has  dissected  the  bladder  off  the  cervix  so  as  to  cut 
across  the  fistulous  tract,  and  closed  the  cut  ends  separately. 


VESICO-  VA  GINAL  FISTULA. 


633 


The  after-dangers  of  the  operation  are  haemorrhage  into  the  bladder  After- 
and  vesical  catarrh.     The  former  is  a  troublesome  complication,  as  the  Operation, 
blood-clots  collect  in  the  bladder ;  when  there  is  marked  haemorrhage 
distending  the  bladder,  the  fistula  must  be  opened  up  again.     Sometimes 
the  ureter  has  been  caught  in  a  stitch  and  compressed ;  intense  pain, 


FIG.  391. 

METHOD  or  REMOVAL  OF  SUTURES  (after  Sinis). 

shooting  from  the  kidney  downwards  along  the  course  of  the  ureter, 
with  vomiting  and  other  symptoms  of  uraemia  followed  but  passed  off 
on  relaxing  the  sutures. 

The  sutures  are  removed  on  the  tenth  day.     The  method  of  remov- Removal  of 
ing  sutures  is  shown  at  figs.  382  and  391. 


Sutures. 


634 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


For  cases  of  fistulae  incurable  by  operation,  a  rubber  urinal  fitted 
into  an  ordinary  ring  pessary  has  been  used.1 


Obliteration  of  Fistulce  by  Cauterisation. 

Cauterisa-       This  treatment  is  only  applicable  to  very  small  fistulse. 
Fistula       mav  be  done  with  nitrate  of  silver  or  the  red-hot  wire. 


Cauterisation 
Where  the 


FIG.  392. 

SIMON'S  OPERATION  FOR  KOLPOKLEISIS.  The  patient  is  in  the  lithotomy  posture ;  the  sound  has 
been  passed  through  the  urethra  and  fistula,  and  is  sesn  in  the  upper  portion  of  the  vagina  ;  the 
perineum  is  drawn  back  with  the  speculum  and  the  labia  majora  with  spatulse.  A  band-like 
piece  of  tissue  has  been  removed  from  both  the  vaginal  walls  above  the  ostitim ;  the  raw  surface 
is  left  unshaded  in  the  figure.  The  vaginal  mucous  membrane  is  held  tense  by  four  pairs  of 
forceps  outside  the  raw  surface,  the  shaded  area  within  the  latter  is  the  upper  third  of  the 
vagina.  An  end  of  the  last  suture  has  been  passed  through  one  raw  surface,  the  second  end  is 
being  carried  through  the  other  raw  surface  (H.  and  K.). 

fistula  is  of  any  size,  cauterisation  not  only  fails  to  close  it  but  converts 
its  margins  into  cicatricial  tissue;   this  makes  its  subsequent  closure 

1  By  J&y—Amer.  Journ.  Obstet.,  1887,  p.  50. 


VESICO-  VA  GIN  A  L  FISTULA . 


635 


with  sutures  more  difficult.  This  method  of  treatment,  even  in  the  case 
of  larger  fistulse,  has  been  recently  revived  and  advocated  by  Bouque, * 
whose  writings  may  be  consulted. 

For  ureteric  fistulse,  nephrectomy  has  been  performed  successfully  by 
Gusserow  and  Josephson. 

Closure  of  the  Vagina :  KolpoTcleisis. 

Where  direct  closure  of  the  fistula  is  impossible,  the  only  means  for 
relieving  the  patient's  discomfort  is  closure  of  the  vagina  below  the 
fistulous  opening.  The  portion  of  the  vagina  above  this  becomes,  as  it 
were,  an  extension  of  the  bladder ;  the  menstrual  blood  is  discharged 
with  the  urine. 

Vidal  de  Cassis,  who  originated  this  operation,  performed  it  as  follows. 
The  inner  surfaces  of  the  labia  majora  were  pared  and  brought  together 
by  sutures  :  the  vulva  was  thus  closed  in  an  antero-posterior  direction. 
After  this  operation,  there  always  remained  just  below  the  urethral 


FIG.  393. 

SAME  OPERATION  AS  SEEN  IN  SECTION  TO  SHOW  RELATION  OF  RAW  SURFACES  (shaded  dark),  position 
of  sutures  and  common  receptacle  above  for  urine  and  menstrual  blood.  The  bladder  and 
urethra  are  in  upper  part  of  figure  (H.  and  K.). 

orifice  a  small  cleft  through  which  the  urine  trickled.     Unless  complete 
continence  is  obtained,  such  an  operation  is  useless. 

Kolpokleisis  is  the  name  given  to  the  operation  introduced  by  Simon.  Simon's 
It  consists  in  obliteration  of  the  vagina  transversely  by  making  a 
surface  on  its  walls  above  the  level  of  the  ostium  vaginae.     It  is  evident 
that  this  operation  is  justifiable  only  where  closure  of  a  fistula  is  impos- 
sible, either  through  the  binding  down  of  its  margins  to  the  bone  with 
cicatricial  tissue  or  through  the  complete  destruction  of  the  urethra. 
As  the  closure  of  the  vagina  interferes  with  married  life,  the  nature  of 
the  operation  should  be  explained  to  the  patient  beforehand  and  full 
permission  obtained. 

The  operation  is  performed  as  follows.     By  pinching  up  the  mucous 

1  "  Du  Traitement  des  Fistules  uro-gen. ;  par  la  reunion  secondaire  : "  Paris,  1875. 


636    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

membrane,  ascertain  where  it  is  most  lax,  so  that  the  vaginal  walls  can 
be  easily  approximated ;  the  point  of  closure  should  be  as  high  up  as 
possible.  Mark  out  with  the  knife  the  ring  of  tissue  to  be  excised. 
Lay  hold  of  its  lower  margin  and  dissect  it  from  below  upwards ;  with 
the  finger  in  the  rectum  and  the  sound  in  the  urethra,  we  can  judge  of 
the  thickness  of  tissue  to  be  removed  (compare  fig.  392  with  fig.  393). 
On  each  ligature  of  wire  or  carbolised  silk,  two  small  curved  needles 
are  threaded  so  that  both  ends  of  the  thread  may  be  passed  from  above 
downwards.  The  needle  must  be  entered  into  the  vaginal  mucous 
membrane  above,  carried  through  the  substance  of  the  vaginal  wall 
(without  appearing  in  the  wound),  and  brought  out  through  the  vaginal 
mucous  membrane  below ;  it  is  difficult  to  prevent  these  sutures  from 
catching  up  either  bladder  or  rectum  but  this  should,  if  possible,  be 
avoided.  Care  is  required  in  the  introduction  of  the  first  mesial  suture 
as  it  is  the  guide  for  the  others. 

The  results  of  this  method  are  satisfactory  as  regards  the  production 
of  complete  continence.  There  is  no  liability  to  stagnation  of  urine  or 
formation  of  concretions  (Hegar  and  KaltenbacJi).  Hsematometra  will 
not  occur  unless  there  has  been  atresia  of  the  cervix  uteri.  If  men- 
struation has  been  in  abeyance,  it  will  probably  return  after  the  opera- 
tion; in  a  case  operated  on  by  A.  R.  Simpson,  the  patient  had  not 
menstruated  for  a  year,  but  a  few  weeks  after  the  operation  the  men- 
strual blood  appeared  in  the  urine. 


CHAPTER   LV. 

THE   RECTUM:    COOOYGODYNIA. 

LITERATURE. 

A  llingham—  Diseases  of  the  Rectum  :  Churchill,  1871.  Chadwick  —  On  the  Functions  of 
the  Anal  Sphincters  :  Am.  Gyn.  Trans.  ,  1877.  Cripps  —  Cancer  of  the  Rectum  : 
Churchill,  1880.  Hart—  Physics  of  the  Rectum  and  Bladder  :  Edin.  Obst.  Trans., 
1882.  Ruedingei  —  Topographisch-chirurgische  Anatomie  des  Menschen,  vierte 
Abtheilung  :  Stuttgart,  1873.  Storei  —  The  Rectum  in  its  relation  to  Uterine 
Disease  :  Am.  Jour,  of  Obst.,  Vol.  I.,  p.  66.  Syme  —  Diseases  of  the  Rectum  :  Edin. 
1859.  Van  Buren  —  Diseases  of  the  Rectum  :  H.  K.  Lewis,  1881.  For  recent 
literature  see  Index  in  Appendix. 

NOT  only  is  the  gynecologist  frequently  consulted  about  rectal  mischief, 
but  as  a  matter  of  fact  female  patients  sometimes  refer  rectal  disease  to 
the  uterus  or  vagina  ;  therefore,  in  investigating  gynecological  cases,  one 
has  occasionally  to  satisfy  one's  self  that  the  rectum  is  not  the  seat  of  the 
affection. 

Vaginismus  may  be  caused  by  fissure  of  the  anus,  as  we  have  already 
seen,  and  pruritus  vulvse  by  ascarides  from  the  rectum  passing  into  the 
vagina. 

PHYSIOLOGY   OF   THE   EECTUM. 

The  anatomy  of  the  rectum  has  been  already  considered  (p.  36).     The  Relation 
relations  of  the  axes  of  rectum,  anus,  vagina  and  urethra,  to  one  another 


and  to  intra-abdominal  pressure  are  of  importance.     As  we  have  already  an(l  Ureth- 
seen,  the  vagina  and  urethra  are  parallel  to  one  another  and  to  the  plane 
of  the  brim. 

Strictly  speaking  the  surface  whose  outer  boundary  is  the  brim  of  the  bony  pelvis  is 
not  a  plane  surface,  inasmuch  as  the  various  points  in  the  outline  of  the  brim  are  not  on 
the  same  level.  The  vagina  is  thus,  properly  speaking,  parallel  to  the  internal  conjugate 
of  the  brim. 

The  rectum  runs,  in  part  of  its  course,  close  behind  the  vagina  for 
1^  inches  and  parallel  to  it  ;  the  anal  canal  turns  directly  backwards  so 
as  to  cut  the  vaginal  axis  at  right  angles.  Intra-abdominal  pressure  acts 
at  right  angles  to  the  vaginal  walls,  as  can  be  noted  from  the  fact  that 
in  defaecation  the  Hodge  pessary  is  not  driven  out  of  the  vagina.  Con- 
sideration of  fig  394  will  show  that  the  direction  of  intra-abdominal 
pressure  on  the  pelvic  floor  coincides  with  the  long  axis  of  the  anus,  so 
that  intra-abdominal  pressure  will  act  with  its  full  driving  force  on  any 
body  in  the  anal  canal. 


638 


AFFECTIONS  OF  BLADDER  AND  RECTUM. 


Mechanism  The  mechanism  of  defalcation  is  probably  the  following.  According 
tion.  '  to  Hilton,  in  his  now  classical  book  on  "Rest  and  Pain,"  the  lower  part 
of  the  rectum  is  sensitive  but  the  upper  two-thirds  are  but  slightly  so; 
the  rest  of  the  large  intestine  and  the  small  intestine  are  non-sensitive. 
Hilton  limits  the  sensitive  portion  to  the  lowest  two  inches  of  the 
rectum — to  the  part  below  the  so-called  sphincter  tertius.  When  there 
is  accumulation  of  fsecal  matter  in  this  portion,  pain  and  uneasiness  pro- 


FIG.  394. 

TO  SHOW  DIRECTION  OF  BECTUM  AND  OF  ANUS  IN  RELATION  TO  INTRA-ABDOM1NAL  PRESSURE. 
a  uterus,  b  bladder,  d  vaginal  orifice, /perineum. 


duce  the  desire  to  expel  these  contents, 
reflex  movements  : — 


There  result  the  following 


(1)  Relaxation  of  the  sphincter  ani; 

(2)  Peristaltic  contraction  of  the  circular  unstriped  muscle ; 

(3)  Shortening  of  the  longitudinal  muscle  with  eversion  of  the 

mucous  membrane.  Since  the  longitudinal  fibres  have  a 
fixed  point  below,  their  contraction  will  probably  pull  the 
rectum  more  into  the  line  of  the  anal  axis ; 

(4)  Contraction  of  the  segments  of  the  sphincter  tertius. 

In  this  way  the  lowest  portion  of  the  rectum  becomes  roofed  in  above 
by  the  sphincter  tertius  and  open  below.  Intra-abdominal  pressure 
drives  this  portion  downwards ;  and  the  rectal  contents,  elongated  by 


THE  RECTUM.  639 

peristalsis  and  depressed  by  intra-abdomiual  pressure  and  eversion  of 
the  mucous  membrane,  are  finally  brought  into  the  relaxed  anal  canal 
from  which  intra- abdominal  pressure  readily  expels  them.  Ruedinger's 
diagram  (fig.  35)  shows  well  how  the  Levator  ani  will  reinvert  the 
everted  mucous  membrane. 

Inattention  to  the  proper  evacuation  of  the  bowels  leads  to  non-sensi- 
tiveness of  the  mucous  membrane  and  is  thus  one  factor  in  constipation. 

EXAMINATION    OP    THE    RECTUM. 

This  may  be  done  in  three  ways  : 

(a)  By  finger  (v.  p.  101), 

(b)  By  speculum, 

(c)  By  eversion  of  the  anterior  rectal  wall  through  digital  pressure 

in  the  vagina  (Storer). 

By  Speculum.     The  anal  speculum  has  usually  an  oval  fenestra ;  it  is  Specular 
passed  into  the  anus  in  the  direction  of  its  long  axis,  and  rotated  so  thattiQU  Of 
each  portion  of  the  anal  lining  comes  opposite  the  aperture  (fig.  396).     Rectum. 

Storer 's  method  is  as  follows.     Place  the  patient  on  her  side  ;  pass  two  Storer's 
fingers  (or  one)  half  way  into  the  vagina,  with  the  pulps  of  the  fingers  * 

on  the  posterior  vaginal  wall.  Then  press  these  downwards  and  back- 
wards, and  thus  evert  the  rectal  mucous  membrane  through  the  dilatable 
sphincter  ani  which  is  at  the  same  time  pressed  open  with  the  fingers  of 
the  other  hand.  This  method  is  most  easily  employed  in  multipart. 

DISEASES    OF    THE    RECTUM. 

Women  are  especially  liable  to  rectal  disease  from  the  distension 
of  parts  accompanying  parturition,  as  well  as  from  their  habitual  neglect 
of  the  regular  evacuation  of  the  bowels.  As  rectal  diseases  often  simu- 
late those  of  the  vagina,  a  sketch  of  the  more  important  of  them  is 
necessary  in  a  Manual  of  Gynecology.  We  shall  therefore  consider  the 
following  affections : — 

Displacements  of  the  rectum, 

Fissure  of  the  anus, 

Piles, 

Recto- vaginal  fistula ; 

Functional  disturbance  of  Rectum — Constipation. 

Displacements  of  the  Rectum. 
These  are — Rectocele ; 

Prolapsus  Recti  (a)  of  mucous  membrane, 

(b)  of  whole  thickness  of  bowel. 

For  Prolapsus  Recti,  which  is  properly  surgical,  see  Van  Buren  or  Prolapsus 
Allingham.  Eecti- 


640    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Rectocele.  Rectocele  is  a  protrusion  of  the  lower  part  of  the  anterior  wall  of  the 
rectum  covered  by  the  posterior  vaginal  wall,  into  the  lumen  of  the 
vagina  or  even  through  the  vaginal  orifice.  Etiology.  There  are  two 
factors — tear  of  perineal  body  and  pressure  of  scybala  in  rectum.  Diag- 
nosis. The  posterior  vaginal  wall  is  seen  protruding  into  the  vagina  or 
out  at  the  vaginal  orifice.  The  diagnosis  is  made  by  noting  the  relations 
of  the  protruded  vaginal  wall  and  by  passing  the  finger  through  the  anus 
into  the  pouch  (fig.  395).  Treatment.  The  patient  should  wear  in  the 
vagina  a  Hodge  or  Albert  Smith  pessary  with  cross  bars ;  explain  the 
necessity  of  a  regular  daily  evacuation  of  the  bowels. 

Fissure  of  the  Anus. 

Fissure  of  This  is  a  crack,  or  ulceration,  of  the  anal  skin  or  of  the  mucous 
membrane  covering  the  internal  sphincter.  In  the  edges  of  the  crack 


FIG.  395. 

RECTOCELE  (Sckroeder). 

there  is  usually  a  nerve  filament,  and  below  the  crack  lies  the  powerful 
sphincter  ani. 

This  apparently  insignificant  lesion  gives  rise  in  most  cases  to  an 
unbearable  and  even  incredible  amount  of  pain,  lasting  for  hours  after 
the  bowels  have  moved.  Hilton's  explanation  of  this  is  so  good  that  we 
give  it  entire. 

Hilton's          "  The  reason  for  this  anal  ulcer  being  so  very  painful  is  the  number 

tion'oT"     °f  nerves  associated  with  it ;  and  the  cause  of  the  continued  painful 

pain  in       contraction  which  accompanies  it  lies  in  the  enduring  strength  of  the 

sphincter  muscle.      Thus  it  happens  that  exposure  of  those  nervous 

sensory  filaments  upon  the  ulcer  causes  excito-motory  or  involuntary  and 

spasmodic  contraction  of  the  sphincter,  through  the  medium  of  the  spinal 


THE  RECTUM. 


641 


marrow.  The  sphincter  muscle  contracts  towards  its  own  centre,  and, 
as  long  as  the  muscle  is  in  a  state  of  contraction,  it  brings  the  sensitive 
edges  of  the  ulcer  into  forced  contact ;  this  excites  more  muscular  con- 
traction, and  thus,  by  time  and  exercise,  the  muscle  becomes  hyper- 
trophied,  massive,  and  increased  in  dimensions." 

Symptoms.     The  patient  complains  not  so  much  of  pain  while  the  Symptoms, 
bowels  are  being  moved  as  of  an  unbearable  pain  coming  on  after  the 
evacuation  and  continuing  for  some  hours.     The    pain   is  described  as 


FIG.  396. 

ANUS  a  WITH  ANAL  SPECULUM  in  situ;  it  is  turned  so  as  to  expose  in  the  fenestra  a  fissure  & 
beneath  which  a  tenotomy  knife  has  been  passed  (Hilton). 

unendurable,  causing  the  patient  to  dread  and  postpone  natural  motions. 
There  are  often  iliac  pains  and  vaginismus ;  this  last  symptom  is  not 
infrequent. 

Physical  signs.     By  speculum  or  eversion,  the  crack  is  seen. 

Treatment.     Chloroform  the  patient,  pass  a  tenotomy  knife  beneath  Treatment, 
the  base  of  the  ulcer  (fig.    396)  and  cut  upwards.     This  divides  the 
muscular  fibre  so  that  the  irritated  edges  can  no  longer  be  brought  to- 
gether.    The  fissure  gets  rest  and  heals  readily ;  a  cure  is  thus  effected. 
2s 


642    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

Another  and  very  good  plan  is  to  chloroform  the  patient,  and  intro- 
ducing the  thumbs  (with  the  dorsal  surfaces  in  contact)  to  stretch  the 
anus  by  forcibly  separating  them ;  this  ruptures  the  muscular  fibre  and 
acts  just  as  the  knife  does,  and  is  especially  good  when  the  fissures  are 
multiple. 

The  bowels  are  not  to  be  moved  for  a  day  or  two ;  the  patient  has 
then  some  pain  when  the  motion  is  passing,  but  none  after  it. 

Piles. 

Hilton  has  pointed  out  that  at  the  anus  the  line  of  demarcation 
between  skin  and  mucous  membrane  is  marked  out  distinctly  by  "  the 
white  line,"  as  he  terms  it.  This  line  is  of  great  practical  importance, 
as  we  shall  see. 

Piles  are  small  tumours  at  the  anus,  on  either  side  of  this  white  line. 
They  consist  of  dilated  veins  embedded  in  connective  tissue  and  covered 
by  skin  or  mucous  membrane.  We  speak  of  external  piles,  i.e.,  those 
outside  of  the  white  line  and  covered  by  skin,  and  internal  piles,  i.e., 
those  inside  of  the  white  line  and  covered  by  mucous  membrane. 
Occasionally  we  have,  as  a  special  form  of  external  pile,  a  dilated  vein 
outside  of  the  white  line  and  usually  containing  a  clot  (venous  pile). 

Symptoms.  Symptoms.  Venous  piles  cause  great  pain ;  while  external  piles, 
unless  inflamed,  occasion  little  inconvenience ;  from  internal  piles, 
there  is  bleeding  when  the  bowels  are  moved. 

Signs.  Physical  signs.     The  venous  pile  is  a  purplish  tumour  outside  of  the 

white  line ;  external  piles  are  like  tags  of  skin,  or  are  more  or  less  dis- 
tended ;  internal  piles  are  cherry-red  and  easily  bleed. 

Treatment.  Treatment.  1.  When  venous  piles  contain  a  clot,  incise  and  turn  out 
clot. 

2.  For  internal  piles,  employ  the  following  palliative  treatment.  Give 
sulphur  confection  when  necessary. 

R     Confectionis  Sulphuris  gij. 

Sig.  Dessertspoonful  at  night. 
Order  gall  and  opium  ointment  to  be  applied. 

R  Unguenti  Gallse  c"  Opio  gij. 

Sig.  As  directed. 

For  any  abrasions,  order  iodoform  ointment  (p.  532)  or  Bismuth  and 
Cocaine  suppositories. 

The  radical  operative  treatment  belongs  more  to  the  surgeon. 

Recto-vaginal  Fistula. 

The  situation  of  such  a  fistula  is  shown  in  fig.  356.  It  may  be  due 
to  carcinomatous  or  syphilitic  ulceration,  or  to  injury  received  during 
parturition.  The  last  only  can  be  operated  on.  It  is  usually  due  to  a 


THE  RECTUM.  643 

tear,  during  labour,  involving  the  anus  and  where  the  lower  part  of  the 
laceration  has  united.  The  best  treatment  is  to  cut  through  the  united 
portion  and  operate  on  it  as  if  it  were  rupture  of  the  perineum  involving 
the  anus. 

Functional  disturbance  of  Rectum — Constipation. 

Women  are  iisually  exceedingly  careless  in  the  matter  of  regulation  of 
the  bowels ;  very  often,  evacuation  is  practised  once  a  week  or  even  at 
longer  intervals.  This  is  in  many  respects  not  their  fault  but  is  due 
to  insufficient  water-closet  accommodation,  to  modesty,  and  to  the  fact 
that  evacuation  is  for  evident  reasons  postponed  during  menstruation. 

When  consulted  for  constipation,  the  medical  man  should  insist  on 
the  value  of  a  daily  evacuation  at  a  fixed  hour ;  this  educates  the 
bowels  to  demand  it  regularly.  All  quack  pills  should  be  tabooed  as 
dangerous.  The  diet  should  be  regulated ;  bran-bread,  porridge  and 
milk,  stewed  fruit,  figs,  etc.,  taken  as  part  of  food.  The  following  pill 
is  good. 

R     Extracti  Nucis  Vomicse 

Extracti  Belladonnse  aa  gr.  \ 

Pilulse  Colocynthidis  et  Hyoscyami       „  iij. 

Fiat  pilula  :  mitte  tales     vj. 

Sig.  One  occasionally. 

The  mix  vomica  and  belladonna  strengthen  the  peristalsis  of  the 
bowel :  the  colocynth  and  hyoscyamus  pill  is  purgative  ;  aloes  and  iron 
pill  may  be  substituted  for  it. 

The  American  drug  Cascara  is  very  useful.  We  may  give  a  pill  of 
three  grains  thrice  daily  until  the  bowels  move ;  twenty  drops  of  the 
liquid  extract  may  be  taken  instead. 

R     Extracti  Cascarse  Sagradse  gr.  iii. 

Pulv.  Glycyrrh  Co.  q.s. 

Fiat  pilula  :  mitte  tales  xij. 
Sig.  One  thrice  daily. 

R     Extracti  Cascarse  Sagradse  Liquid!  §ij. 

Sig.  Twenty  drops  thrice  daily. 

This  drug  is  tonic  to  the  bowels :  its  use  should  be  stopped  when 
once  the  bowels  begin  to  act.  It  should  not  be  given  until  the  diet  is 
regulated.  The  pill  is  more  convenient,  as  the  liquid  extract  is  bitter. 

The  purgative  mineral  waters  are  very  useful.  The  best  are  the 
Friedrichshall,  Hunyadi  Janos  and  Aesculap.  The  patient  should  take 
in  the  morning  a  wine-glassful  or  half-tumblerful  with  an  equal  amount 
of  hot  water ;  the  taste  may  be  masked  by  the  juice  of  a  lemon  with 
sugar.  The  Carlsbad  salts  are  good  and  may  be  used  as  already  directed 
(p.  340).  Very  often  an  enema  of  cold  water  is  helpful.  The  medical 


644    AFFECTIONS  OF  BLADDER  AND  RECTUM. 

man  should  deprecate  the  habitual  use  of  purgatives,  and  insist  on 
natural  and  daily  evacuation. 

The  aloes  and  iron  pill  is  good  in  sluggishness  of  the  lower  bowel. 
Rhubarb  is  bad  as  a  habitual  purgative,  owing  to  its  tendency  to  con- 
stipate after  purging ;  the  well-known  "  Gregory's  Mixture  "  should  not 
be  used  as  a  habitual  purgative,  but  is  good  in  diarrhoea  inasmuch  as  it 
first  purges  and  then  binds.  Fluid  magnesia,  castor  oil,  and  some  of  the 
milder  salines  (e.g.,  the  easily-taken  Seidlitz  powder)  may  be  employed. 
Blue  pill  should  be  avoided;  Euonymin  or  Iridin  are  better  hepatic 
stimulants  (v.  p.  584). 

It  has  been  recently  found  that  the  injection  of  pure  glycerine  (3J-3J) 
into  the  rectum  ensures  an  evacuation  of  the  lower  bowel  in  a  few 
minutes.  It  is  therefore  convenient  in  certain  cases.  Suppositories 
made  up  in  large  part  of  glycerine  can  also  be  employed.  A  small 
syringe  is  required  for  the  injection  of  the  fluid  glycerine. 

OOCOYGODYNIA. 

LITERATURE.  Hildebrandt — Die  Krankheiten  der  ausseren  weiblichen  Genitalien,  S. 
127 :  Stuttgart,  1877.  Nott— N.  O.  Medical  Journal,  May  1844.  Simpson,  Sir  J. 
T. — Diseases  of  Women,  p.  202  :  Edinburgh,  1872.  Thomas — Diseases  of  Woman, 
p.  151 :  London,  1880.  For  recent  literature  see  ' '  Miscellaneous "  in  Index  of 
Literature  in  the  Appendix. 

By  this  we  understand  a  painful  condition  in  the  region  of  the  coccyx 
induced  by  sitting,  walking,  and  the  various  muscular  contractions 
associated  with  defsecation  and  coitus.  When  we  consider  the  anatomy 
of  the  coccyx,  its  muscular  attachments  (to  the  levator  ani,  coccygeus, 
external  sphincter  ani,  and  gluteal  muscles),  as  well  as  the  strain  put  on 
it  when  driven  back  during  parturition,  we  are  not  astonished  that  in 
some  cases  there  should  be  inflammatory  changes  around  and  in  it 
causing  pain  in  its  movement. 

Symptoms.  The  chief  symptom  is  pain  on  sitting,  walking,  and 
defsecation. 

Physical  signs.  By  digital  pressure  on  the  coccyx  and  examination 
per  rectum,  the  seat  and  nature  of  the  pains  are  made  out. 

Treatment.  (1)  Massage  and  manipulation  of  the  coccyx  should  be 
tried  first.  (2)  Pass  a  tenotomy  knife  beneath  the  skin  on  the  posterior 
aspect  of  the  coccyx,  and  free  its  lateral  and  apical  muscular  attach- 
ments ;  or  (3)  amputate  the  coccyx.  To  do  the  latter,  make  a  vertical 
mesial  incision  over  the  posterior  aspect  of  the  coccyx ;  seize  its  tip  and 
pull  it  well  back ;  then  free  its  muscular  attachments  with  the  knife, 
keeping  close  to  the  bone ;  finally  separate  it  at  the  sacro-coccygeal 
joint. 


APPENDIX. 

ABDOMINAL  SECTION. 

LITERATURE. 

Harbour — The  Diagnosis  of  Advanced  Extra- uterine  Gestation  :  Ed.  Med.  Journ.,  1882. 
Hart — The  Minute  Anatomy  of  the  Placenta  in  Extra-uterine  Gestation  :  Ed.  Med. 
Journ.,  Oct.  1889.  Hart  and  Carter — The  Sectional  Anatomy  of  Advanced  Extra- 
uterine  Gestation:  Edin.  Med.  Journ.,  Oct.  1887.  And  Laboratory  Reports,  R.C.P.E.  : 
Edin.,  1889.  Jessop — Case  of  Extra-uterine  Gestation ;  removal  of  living  foetus,  etc. : 
Lond.  Obstet.  Trans. ,  1876,  p.  261.  Keith— Surgical  Treatment  of  Tumours  of  the 
Abdomen  :  Edin.  1885.  Langenbuch — International  Medical  Congress,  London,  1881, 
Vol.  II.,  p.  278.  Lister— On  Corrosive  Sublimate  as  a  Surgical  Dressing :  Lancet, 
1884,  p.  723.  Macdonald— Record  of  Cases  treated  in  Ward  XXVIII.,  Royal 
Infirmary,  Edinburgh,  Nov.  1883  to  April  1884:  Edin.  Obstet.  Trans.,  vol.  IX.,  p. 
134  ;  same  from  May  to  November  1884  :  ibid.  X.,  p.  178.  Maygrier — Terminaison 
et  Traitement  de  la  Grossesse  extra-uterine :  Paris,  1886.  Morris — Surgical  Diseases 
of  the  Kidney  :  London,  Cassell  &  Co.,  1885.  Tait,  Lawson — Diseases  of  the 
Ovaries :  Birmingham,  Cornish  Brothers,  1883.  Ectopic  Pregnancy  and  Pelvic 
Hsematocele :  Birmingham,  1888.  The  Pathology  and  Treatment  of  Extra-uterine 
Gestation  :  Brit.  Med.  Journ.,  1884,  p.  317.  Thornton,  J.  Knoivsley — Cases  of 
Hysterectomy,  etc.  :  Brit.  Med.  Journ.,  May  23,  1885.  Treves,  F. — Intestinal 
Obstruction  :  London,  Cassell  &  Co.,  1884.  Wells,  Sir  Spencer — The  Diagnosis  of 
Surgical  Treatment  of  Abdominal  Tumours  :  London,  Churchill,  1885.  See  also 
Literature  of  Operative  Treatment  of  Ovarian  Tumours,  Chap.  XXIV.,  and  Treat- 
ment of  Fibroid  Tumours,  Chap.  XXXVII. ;  all  references  to  recent  papers  will  be 
found  under  "Abdominal  Surgery,"  in  the  Index  in  Appendix. 

IN  this  chapter  a  short  summary  will  be  given  on  this  important 
subject.  In  the  preceding  pages  operations  necessitating  abdominal 
section,  viz.  those  for  abdominal  and  pelvic  tumours,  have  been 
described ;  but  this  chapter  is  intended  to  gather  up  consecutively  and 
briefly  the  main  points  necessary  for  the  successful  performance  of 
Abdominal  Section  so  as  to  give  the  operator  or  his  assistant  a  bird's 
eye  view  of  the  whole  subject  and  enable  him  to  meet  unexpected 
emergencies  such  as  often  arise  even  after  the  iitmost  care  has  been 
taken  to  avoid  mistakes  in  diagnosis. 

Preliminaries.  The  operation  is  best  performed  in  the  special  wards 
of  an  hospital  or  in  a  private  hospital  in  the  case  of  well-to-do  patients. 
The  houses  of  the  poor  are  quite  unfitted  for  operations  ;  and  it  is  much 
better  for  wealthy  patients  to  be  under  the  discipline  of  a  good  private 
hospital  and  away  from  the  well-meaning  but  hurtful  interference  of 
relatives.  It  also  relieves  the  operator  of  the  anxieties  attendant  on 
their  misinterpretation  of  symptoms. 


646  APPENDIX. 

Prior  to  any  operation  the  patient's  systems  should  be  examined, 
especially  lungs,  heart,  and  kidneys.  Ether  is  better  not  employed 
when  there  is  a  tendency  to  bronchitis :  and  the  amount  of  urine 
should  be  noted,  the  usual  tests  for  albumen  and  sugar  employed,  and 
microscopical  examination  made  of  its  deposit.  The  urine  is  some- 
times scanty  in  cases  of  large  tumours,  and  therefore  some  diuretic  such 
as  acetate  or  citrate  of  potash  should  be  given. 

The  pulse  and  temperature  should  also  be  taken  twice  daily  for  a 
few  days  prior  to  operation. 

The  importance  of  having  a  specially  trained  nurse  cannot  be  over- 
rated. She  is  required  to  take  the  pulse  and  temperature,  and  to  keep 
a  register  of  these  :  to  draw  off  the  urine  when  necessary  and  to  be 
capable  of  giving  ordinary  and  nutritive  euenmta.  She  must  therefore 
have  good  hands,  be  firm  and  yet  gentle,  -one  who  carries  out  instruc- 
tions to  the  letter,  and  who  is  thoroughly  imbued  with  the  spirit  of 
cleanliness. 

ANTISEPTICS. 

The  operation  is  to  be  carried  out  in  the  spirit  of  Listerism.  The 
operator  strives  to  have  pure  siirroundings  and  everything  that 
touches  the  part  operated  on  aseptic,  either  by  antiseptics  or  sterilisa- 
tion. He  must  therefore  consider  means  of  purifying  the  air,  instru- 
ments, sponges,  skin  of  patient  adjacent  to  part  operated  on,  and  discharges 
from  wounds. 

Purification  of  the  air.  This  is  to  be  got  by  ventilation,  previous 
purification  of  the  room  by  sulphur  or  chlorine  fumigation,  and  pre- 
liminary spraying  of  carbolic  lotion  into  the  air  of  the  apartment. 
The  spray  need  not  be  used  during  the  operation  as  it  may  have  an 
injurious  effect  on  the  tissues  and  peritoneum.  The  operator's  great 
aim  is  to  lower  the  health  of  the  tissues  as  little  as  possible  and  not 
to  irritate  the  peritoneum  nor  hinder  its  absorptive  power.  He  is 
to  attach  the  greatest  importance  to  the  absolute  asepticity  of 
everything  that  touches  the  wound — fingers,  knives,  and  (above  all) 
sponges. 

Instruments  are  readily  purified  either  by  boiling  water  or  by  soaking 
in  carbolic  lotion  (1-20  of  water).  During  the  operation  they  should 
lie  in  shallow  porcelain  trays  of  1-40  carbolic  lotion. 

Sponges.  This  is  the  part  of  the  operative  equipment  which  requires 
most  careful  attention.  The  utmost  cleanliness  and  purification  of 
sponges  is  a  sine  qua  non  to  success.  Care  must  be  taken  that  they 
do  not  become  friable  and  the  operator  should  give  them  his  personal 
attention. 

As  an  exemplar  of  what  is  required,  we  give  Lawson  Tait's  precau- 
tions in  regard  to  them. 


ABDOMINAL   SECTION.  647 

"New  Sponges  are  first  put  into  a  large  quantity  of  water  with  sufficient  muriatic  Mode  of 
acid  to  make  the  water  taste  disagreeably  acid.  They  remain  in  this  mixture  until  all  cleaning 
effervescence  has  ceased  and  all  the  chalk  is  removed.  For  this  purpose  it  may 
necessary  to  renew  the  acid  several  times.  The  Sponges  are  afterwards  carefully  and 
thoroughly  washed  to  make  them  as  clean  as  possible  and  free  from  every  rough  particle. 
After  being  used  at  an  operation  they  are  first  washed  free  from  blood,  and  then  put  in 
a  deep  jar  and  covered  with  soda  and  water  (1  Ib.  of  soda  to  twelve  sponges).  They  are 
left  in  this  about  twenty-four  hours  (or  longer  if  the  sponges  are  very  dirty),  and  then 
they  are  washed  perfectly  free  from  every  trace  of  soda.  This  takes  several  hours'  hard 
work,  using  hot  water,  squeezing  the  sponges  in  and  out  of  the  water,  and  changing  the 
water  constantly.  Leaving  them  to  soak  occasionally  for  a  few  hours  in  very  hot  water 
greatly  assists  in  the  cleansing.  When  quite  clean  they  are  put  into  a  jar  of  fresh  water 
containing  about  one  per  cent,  of  carbolic  acid,  and  after  being  in  this  for  twenty-four 
hours  they  are  squeezed  dry  and  tied  up  in  a  white  cotton  bag,  in  which  they  are  left 
hanging  from  the  kitchen  ceiling  (being  the  driest  place  in  the  house)  till  they  are 
wanted." 

Prior  to  an  operation  they  should  be  carefully  washed  in  very  hot 
water  and  soaked  over  night  in  carbolic  lotion  (1-20). 

They  are  wrung  out  of  1-40  for  the  operation  and  placed  near  the 
operator  in  a  suitably  warmed  dish. 

The  skin  near  the  part  to  be  operated  on  should  be  washed  the 
night  before  the  operation  with  turpentine,  soap,  and  water.  The 
umbilicus  is  to  be  carefully  cleansed.  When  the  patient  is  under 
chloroform,  the  skin  is  again  washed  with  corrosive  sublimate  (1-2000) 
and  the  pubes  shaved. 

The  operator's  hands  are  to  be  cleansed  with  turpentine,  soap,  and 
water :  the  nails  brushed,  and  all  finally  washed  with  corrosive  sub- 
limate (1-2000).  One  good  rule  is  that  only  the  operator  or  the 
special  assistant  should  touch  the  wound,  sponges,  and  instruments. 
No  one  else  should  do  so  unasked. 

THE   ABDOMINAL   INCISION. 

This  is  either  mesial  or  lateral.  The  mesial  incision  is  the  usual  one 
and  may  vary  in  length. 

For  an  exploratory  incision,  two  inches  is  sufficient,  and  this  is  also, 
as  a  rule,  enough  for  the  removal  of  the  uterine  appendages  in  the 
pelvis.  Its  lower  end  is  one  inch  above  the  symphysis  pubis  but  must 
be  higher  when  removing  the  uterine  appendages  in  an  abdominal 
fibroid. 

For  ovariotomy,  an  incision  of  3  to  4  inches  in  length  is  usually 
required. 

For  large  solid  tumours,  the  incision  may  be  very  long. 

If  the  first  incision  into  the  abdominal  cavity  is  found  too  short,  it 
can  easily  be  enlarged  up  and  down  with  straight  probe-pointed  scissors 
guided  on  the  finger  passed  in. 

The  operator  cuts  down  through  the  skin  and  abdominal  fat  to  the 
aponeurosis.  Beneath  the  aponeurosis  is  the  extra-peritoneal  fat  and 


648  APPENDIX. 

then  the  peritoneum.  A  good  plan  is  to  lay  hold  of  the  structures 
beneath  the  aponeurosis  with  two  pairs  of  Pean's  forceps,  each  one  catch- 
ing a  little  to  the  side  of  the  mesial  line.  In  this  way  a  fold  is  pinched 
up,  running  across  the  middle  line  at  right  angles  to  it :  this  can  be  cut 
without  danger  to  subjacent  structures  and  the  same  manoeuvre  repeated 
on  deeper  stmctures. 

The  lateral  incision  of  Langenbuch  is  to  be  recommended  in  renal 
tumours.  It  is  made  at  the  outer  margin  of  the  rectus  abdominis 
with  its  centre  at  the  level  of  the  umbilicus  and  is  advantageous 
inasmuch  as  the  operator  reaches  the  outer  layer  of  the  meso-colon,  thus 
avoiding  the  blood-vessels  running  in  the  inner  layer. 

EXPLORATION^OF   ABDOMEN    OR    PELVIS    AND    REMOVAL    OF    TUMOURS. 

When  the  abdominal  cavity  is  opened  the  operator  either  explores 
in  doubtful  cases  or  removes  the  tumour  he  has  already  diagnosed. 

While  exploring,  the  deep  anesthetization  of  the  patient  removes 
all  straining  of  the  abdominal  muscles.  The  operator  may  find  that 
he  has  to  deal  with  a  malignant  case,  or  with  a  tumour  not  removable. 
He  must  then  close  the  incision.  One  good  rule  in  doubtful  cases  is 
not  to  meddle  unless  there  is  a  fair  chance  of  finishing  the  case.  It  is 
always  unwise  for  the  operator,  and  highly  dangerous  to  the  patient,  to 
nibble,  as  it  were,  at  a  case.  There  is  little  or  no  risk  in  mere 
exploratory  incision. 

The  removable  tumours  or  conditions  admitting  treatment  are — 

(1)  Ovarian,  parovarian,  and  broad-ligament  tumours, 

(2)  Fibroid, 

(3)  Fibro-cystic, 

(4)  Splenic, 


(5)  Omental, 

(6)  Renal, 

(7)  Hydatid, 

(8)  Mesenteric, 

(9)  Pancreatic, 

(10)  Distended  gall  bladder, 
Xll)  Uterine  appendages  in  cases  of  fibroids, 
/  (12)  Uterine  appendages  diseased  (pyosalpinx,  cirrhotic 

•>       j  or  prolapsed  and  painful  ovaries), 

g       j  (13)  Pelvic  abscess, 

^(14)  Extra-uterine  gestation. 

(1)  Ovarian,  parovarian,  etc.  The  removal  of  these  by  Abdominal 
Section  has  already  been  fully  described  under  Ovariotomy,  in  Chap. 
XXIV.  The  operation  for  a  pediculated  tumour  may  thus  be  briefly  sum- 
marised. The  operator  taps  the  tumour,  withdraws  it  from  the  abdomen 


ABDOMINAL   SECTION.  649 

and  ties  the  pedicle  with  the  Staffordshire  or  the  ordinary  knot.  In 
certain  cases  or  in  all  (Keith")  the  clamp  and  cautery  can  be  employed. 
The  tumour  is  now  cut  away  :  the  pedicle  whether  ligatured  or  cauterized 
is  dropped  back  (complete  intra-peritoneal  treatment)  and  the  abdominal 
incision  closed. 

When  the  tumour  (usually  papillomatous)  has  developed  between  the 
layers  of  the  broad  ligament  or  beneath  the  peritoneum  and  is  not 
pediculated,  its  removal  is  a  much  more  difficult  matter.  The  best  plan 
is  to  tap  first,  then  to  incise  the  peritoneum  and  enucleate  the  tumour. 
The  part  first  enucleated  with  the  finger  is  laid  hold  of  with  forceps, 
drawn  well  up,  and  then  the  operator  separates  further  with  his  finger, 
seizing  bleeding  points  with  Pean's  forceps  and  tying  with  catgut.  Care 
must  be  taken  at  the  side  walls  of  the  pelvis  not  to  damage  the  ureter, 
as  well  as  at  the  region  of  the  sacro-iliac  joints  where  the  large  iliac 
veins  with  their  many  branches  lie.  The  part  from  which  the  tumour 
has  been  enucleated  should  be  drained  if  necessary. 

(2)  (3)  Fibroid  and  Fibro-cystic.     For  full  details  of  Hysterectomy  for  Removable 
Fibroids,  see  pp.  432-442.     The  tumour  is  turned  out  of  the  abdomen  Tumours, 
through  a  large  incision,  clamped,  and  then  cut  off.      The  pedicle  is 
usually  treated  extra-peritoneally. 

(4)  Splenic.  Cystic  splenic  tumours  have  been  removed  successfully. 
In  Leucocythsemic  cases  the  spleen  should  not  be  removed. 

(6)  Renal.       After   incising   the   abdominal   walls  by  Langenbuch's 
incision, J  the  outer  layer  of  the  meso-colon  is  opened,  the  renal  vessels 
secured,  and  if  tied  separately,  the  artery  is  to  be   tied  first.       The 
ureter   is   grasped  with  two  ovariotomy  forceps  and  divided  between. 
The  tumour  is  now  enucleated,  the  vessels  cut  on  the  tumour  side  of 
the  ligature  and  the  tumour  removed. 

The  ureter  is  now  tied  and  its  end  secured  in  the  abdominal  incision. 

(7)  (8)    Hydatids   or  Mesenteric   tumours  are    opened,   the    contents 
evacuated,   and   the   incision   into   them    stitched   to   the    abdominal 
wound. 

(10)  Distended  gall  bladder.  The  gall  bladder  when  distended  owing 
to  obstruction  by  gall  stones,  has  been  opened,  the  calculi  removed 
(recommended  by  Jean  Louis  Petit,  Handfeld  Jones,  and  carried  into 
execution  by  Marion  Sims,  and  especially  Lawson  Tait).  Tait,  in  one 
of  his  cases,  made  an  incision  4  inches  in  length,  in  the  middle  line, 
with  the  umbilicus  in  the  centre  of  the  incision.  The  gall  bladder  was 
aspirated  after  the  abdomen  was  opened,  and  then  cut  into  at  that  point; 
the  gall  stones  were  extracted,  the  opening  in  the  gall  bladder  stitched  to 
the  abdominal  wound,  and  the  rest  of  the  wound  closed  in  the  usual 

1  On  this  subject  the  student  may  read  Morris'  Surgical  Diseases  of  the  Kidney  (London  1885),  and 
also  Czerny's  paper  "  Ueber  Nierenextirpation,"   with   discussion   in   the   International  Congress 
Transactions  ;  London  1880,  Vol.  II.,  p.  242. 

2  See  specially  Lawson  Tail's  article. 


650  APPENDIX. 

way.     Bile  oozed  from  the  wound  for  some  days,  but  the  patient  made 
an  excellent  recovery. 

(11)  Uterine  appendages  in  case  of  Fibroids.     When  a  fibroid  is  not  too 
large  and  is  growing  rapidly  or  causing  exhausting  haemorrhages,  the 
appendages  should  be  removed.     A  two-inch  incision  is  made  through  the 
abdominal  wall  and  the  ovary  and  Fallopian  tube  on  either  side  brought 
up  to  it.     The  ovary  and  part  of  the  Fallopian  tube  are  looped  up,  tied 
with  the  ordinary  or  the  Staffordshire  knot,  and  the  parts  outside  the 
ligature  cut  off.     In  this  way  the  ovary  and  part  of  tube  are  removed. 

(12)  Uterine  appendages  diseased  (pyosalpinx,  cirrhotic  or  prolapsed  and 
painful  ovaries).     The  uterine  appendages  when  diseased  and  causing 
serious  indisposition  may  be  removed.     This  is  not  by  any  means  to  be 
done  lightly,  its  exact  results  as  to  sterility  have  to  be  explained,  and 
the  operator  should  never  force  it  on  the  patient. 

In  Pyosalpinx  the  operator  first  taps,  then  loops  up  the  tube,  freeing 
adhesions  with  his  fingers,  ligatures  as  large  a  loop  as  possible  and  cuts 
away  above.  Great  care  is  to  be  taken  to  prevent  any  pus  entering  the 
abdomen.  This  is  best  done  by  pressing  sponges  below  the  freed  tube. 
Any  haemorrhage  is  arrested  by  pressure,  ligature,  hot  water,  or  by  the 
actual  cautery.  Some  operators  prefer  to  separate  adhesions  before 
tapping.  Should  the  tube  rupture  during  this,  the  extravasated  contents 
must  be  most  carefully  sponged  out  and  the  pelvis  thoroughly  flushed 
with  hot  water. 

(13)  Pelvic  abscess  may  be  treated  by  abdominal  section  when  it  rises 
up  so  as  to  be  near  the  abdominal  walls.      After  the   usual   incision 
through  the  walls,  the  operator  taps  the  swelling,  then  draws  up  the 
collapsed  walls  of  the  cavity,  enlarges  the  opening,  and  stitches  it  with 
silk  to  the  abdominal  wall,  the  rest  of  the   abdominal  incision  being 
closed  as  usual.     A  glass  drainage  tube  is  passed  into  the  abscess  cavity, 
but  the  peritoneal  cavity  is  accurately  closed. 

Forms  of        (14)  Extra-uterine  gestation  may  be  met  with  in  very  many  forms:  — 

Gestation  /(a)  Entire,  small,  and  still  in  Fallopian  tube  ; 

(6)  Ruptured  into  the  peritoneal  cavity,  which  contains  much 
blood  and  a  small  foetus  ; 

(c)  Ruptured  through  the  part  of  the  Fallopian  tube  bounded  by 

the  broad  ligament,  and  developing  there  ; 

(d)  Both  foetus  and  placenta  near  full  time  but  lying  in  extra- 

peritoneal  tissue  ; 

(e)  Foetus  in  peritoneal  cavity  with  placenta  in  extraperitoneal 


tissue 


> 

(/)  Foetus  and  placenta  in  extraperitoneal  tissue  but  suppuration 

going  on  and  termination  as  in  pelvic  abscess ; 
(g}  In  a  detached  horn. 


ABDOMINAL   SECTION.  651 

(a)  Entire,  small,  and  still  in  Fallopian  tube.  Here  the  operator  tries 
to  remove  the  entire  sac  by  ligature  with  silk  and  cutting  away  above  it. 

(6)  Ruptured  into  the  peritoneal  cavity  which  contains  much  blood  and  a 
small  foetus.  Such  cases  may  be  saved  by  Abdominal  Section.  Tait  has 
recorded  no  fewer  than  43  cases  where  he  has  operated  for  this  with  only 
one  death. 

In  a  recent  case  of  abdominal  section  we  found  the  pelvis  filled  with  tarry-like  blood,  a 
small  foetus  in  the  abdomen,  and  a  rupture  in  the  Fallopian  tube  about  the  size  of  the  tip 
of  the  index  finger.  The  foetus  was  removed,  a  loop  of  the  tube  with  the  rupture  on  it 
secured  with  the  Staffordshire  knot,  the  pelvis  sponged  and  then  washed  out  with  hot 
water  (120°  F.),  to  check  oozing.  It  was  noted  at  the  time  that  the  omentum  became 
blanched  ;  the  water  was  passed  in  only  for  a  few  seconds  and  then  sponged  out.  Unin- 
terrupted recovery  took  place. 

(c)  Ruptured  through   the  part  of  the  Fallopian  tube  bounded  by  the 
broad  ligament,  and  developing  there.       This  gives  a  complex  case  not 
good  for  abdominal  section.     The  operator's  aim  should  be  to  open  the 
sac  and  remove  the   foetus  without  disturbing  the   placenta.       In  all 
extra-uterine   gestation,  indeed,    it  is    absolutely  imperative    to  avoid 
removing  the  placenta,  as  there  is  no  arrangement  of  muscular  fibre  to 
check  htemorrhage  as  in  normal  labour.     The  cut  edge  of  the  sac  is  to 
be  stitched  to  the  abdominal  wound  and  a  drainage  tube  inserted. 

In  a  case  observed  by  us  the  placenta  had  grown  after  the  death  of  the  foetus ;  the 
foetus  was  very  much  compressed  and  any  attempt  to  remove  it  by  abdominal  section 
would  have  caused  fatal  haemorrhage  by  separating  the  placenta. 

(d)  In  this  form  a  lateral  incision  may  be  employed  and  access  gained 
without  opening  the  peritoneal  cavity.     The  foetus  can  be  removed  and 
the  placenta  left. 

(e)  As  in  (d)  except  that  the  peritoneal  cavity  is  opened  by  a  mesial 
incision. 

(/)  Is  to  be  treated  as  in  pelvic  abscess. 

(g)  Gestation  in  a  detached  horn.  This  is  a  very  rare  condition  and  is 
of  interest  chiefly  because  of  its  close  resemblance  to  a  fibroid  (v.  p.  263). 
It  is  removed  and  clamped  just  like  a  fibroid. 

POSSIBLE   ACCIDENTS    DURING    LAPAROTOMY. 

The  accidents  which  may  happen  during  Laparotomy  are  usually, 
though  not  always,  due  to  the  non-observance  of  the  rules  now  laid  down 
by  successful  operators,  and  should  not  occur  when  these  are  followed. 
They  may  be  thus  summed  up. 

(1)  Leaving  sponges  or  instruments  in  the  abdomen, 

(2)  Wound  of  small  intestine, 

(3)  Injury  to  tip  of  vermiform  appendix, 

(4)  Injury  to  ureter, 

(5)  Injury  of  iliac  veins, 

(6)  Tears  into  bladder  or  rectum. 


652  APPENDIX. 

Sponges  or  instruments  will  not  be  left  in  the  abdomen,  if  they  are 
carefully  counted,  and  the  former  never  torn  up  during  an  operation.  A 
fatal  result  may  follow  if  such  foreign  bodies  are  left,  although  cases 
have  been  recorded  where  they  have  been  removed  on  the  following  day, 
or  even  been  discharged  many  days  after,  the  patient  recovering ;  in  the 
last  cases  they  have  set  up  abscesses  escaping  by  the  bladder  or  wound. 
Wound  of  the  small  intestine  should  be  stitched  as  follows.  First 
stitch  mucous  membrane  to  mucous  membrane  with  catgut  and  then 
peritoneum  to  peritoneum  by  Lembert's  suture.  The  material  to  be  used 
for  the  peritoneum  is  the  finest  Chinese  twist,  passed  with  a  curved 
needle. 1 

PERITONEAL   TOILETTE;    CLOSURE    OF    WOUND. 

The  peritoneal  toilette  must  be  performed  most  carefully.  All  bleed- 
ing points  are  to  be  arrested  and  all  fluids  are  to  be  sponged  out 
thoroughly.  The  pelvis  or  abdominal  cavity  if  necessary  may  be  washed 
out  with  warm  water.  The  peritoneum  should  be  made  thoroughly  dry 
before  the  wound  is  closed.  Careful  peritoneal  toilette  with  scrupulous 
asepsis  is  the  key  to  success. 

The  abdominal  wound  may  be  closed  with  silk  or  silkworm  catgut. 
Silk  is  very  good  and  the  stitches  may  be  passed  as  in  an  ordinary 
wound.  They  should  not  be  far  apart  (half  an  inch  or  so  between 
each),  and  should  include  the  whole  thickness  of  the  abdominal  walls. 
The  skin  if  necessary  may  be  more  accurately  approximated  by  super- 
ficial horsehair  stitches. 

Some  operators  unite  the  peritoneal  edges  with  catgut  and  then  use 
silk  for  muscle  and  skin. 

ELECTRICITY    IN    GYNECOLOGY:    THE    APOSTOLI 
METHOD    OP    TREATMENT. 

Keith's  INTRODUCTORY. — The  history  of  the  employment   of  Electricity   in 

ofPthe°n      Gynecology  has  already  been  referred  to  under  Treatment  of  Fibroid 

Apostoli     Tumours  of  the  Uterus  (p.  427).     We  should  call  especial  attention  to 

Treatment.  *ne  closing  sentence  in  the  passage  cited  from  T.  Keith  on  p.  428  : — 

"  What  I  now  plead  for  is,  that  for  a  time  all  bloody  operations  for  the 

treatment   of  uterine   fibroids   should   cease,   and   that   Dr   Apostoli's 

treatment  as  practised  by  him  should  have  a  fair  trial."     In  the  same 

connection,  we  shoxild  also  quote  from  the  dedication  to  Dr  Apostoli,  by 

the  same  author  in    the   book  by  himself  and  Skene  Keith    on  The 

Treatment  of  Uterine  Tumours  by  Electricity2: —  "Since  we  began  your 

treatment,  now  more  than  two  years  ago,  we  have  ceased  to  perform 

any  operation  on  the  uterus  by  abdominal  section.  .  .  .  For  long,  I 

had  hoped  much  from  electricity  in  the  treatment  of  fibroids,  but  had 

only  met  with  disappointment  till  your  method  was  made  known  to  me." 

1  See  Treves'  Intestinal  Obstruction.  2  Edinburgh,  Oliver  &  Boyd,  1889. 


ELECTRICITY  IN  GYNECOLOGY.  653 

Accordingly,  it  is  in  the  line  of  following  out  Keith's  advice,  that 
we  limit  this  short  chapter  to  a  statement  of  Apostoli's  method  of 
Electrical  Therapeutics  in  Gynecology,  without  at  present  expressing  a 
judgment  as  to  the  permanent  value  of  that  form  of  treatment. 

HISTORY. — Apostoli  tells  us  that  he  studied  the  surgical  employment  History 
of  electricity  at  the  Clinique  of  Dr  A.  Tripier  whose  memoir  to  the^^toli 
Academy  of  Science  in  Paris,  on  Faradisation  in  the  Treatment  ofMethod- 
Hypertrophies  of  the  Uterus,1  opened  up  the  way.  Apostoli  saw  the 
weak  points  of  Tripier's  practice :  among  others,  that  the  currents 
employed  were  too  feeble,  their  intensity  not  regulated  and  measured, 
the  point  of  application  wrongly  chosen,  and  the  different  effects  of  the 
Faradic  and  the  Galvanic  (or  Voltaic)  currents,  as  well  as  of  the  positive 
and  the  negative  poles  not  distinguished.  He  began  to  work  out  his 
own  ideas  in  1882  ;  and  in  1883,  he  described  his  electric  treatment  of 
Perimetritis,  reading  a  paper  on  that  subject  at  the  Congress  of 
Copenhagen  in  18S4.2  In  this  same  year  (1884)  he  laid  a  memoir  on 
the  subject  of  Treatment  of  Fibroid  Tumours  of  the  Uterus  by 
Electricity  before  the  Academy  of  Medicine  of  Paris ;  the  subject,  as 
already  mentioned  (p.  427),  of  his  paper  read  at  the  Dublin  meeting  of 
the  British  Medical  Association  in  1887.  It  was  also  in  1887  that  he 
published  a  book  on  the  Electric  Treatment  of  Chronic  Metritis  and 
Endometritis.5  In  conclusion,  we  should  mention  his  papers  "On 
Some  New  Applications  of  the  Induced  or  Faradic  Current  in  Gyne- 
cology "4  and  "On  the  Treatment  of  Salpingitis,"5  and  that  in  1888  he 
was  able  to  point  to  many  distinguished  British  and  American  gynecologists 
who  had  adopted  his  method.  Notable  among  these,  is  Thomas  Keith ; 
and  we  close  this  historical  note  by  again  referring  to  the  treatise,  by 
himself  and  his  son  Skene  Keith,  which  has  just  appeared  and  may  be 
said  to  complete  the  introduction  of  the  Apostoli  method  to  the 
medical  profession  in  this  country.  It  is  the  detailed  account  of  the 
first  one  hundred  and  six  consecutive  cases  of  Uterine  Tumours  treated 
by  electricity ;  and  in  the  conclusion  of  his  dedication  to  Apostoli 
Thomas  Keith  says — "  That  you  will  in  a  few  years  see  your  treatment 
adopted  all  over  the  world  I  have  little  doubt ;  and  no  one  can  wish 
you  success  more  heartily  than  I  do." 

NOTE  ON  ELECTRICAL  TERMS  USED.  —  In  order  to  make   clear  the 
description  of  Apostoli's  method  which  follows,  it  will  be  well  first  to 

1  Hyperplasies  conjunctives  des  organes  contractiles  de  1'emploi  de  la  faradisation  dans  le  traite- 
ment  des  engorgements  et  deviations  do  1'uterus  et  de  1'hypertrophie  prostatique  :  Comptes  Rendus 
de  V  Academic  des  Sciences,  Aoilt  1859.     Lecons  de  clinique  sur  les  maladies  des  feiumes  :  Paris,  Octave 
Doin,  1883. 

2  Sur  un  nouveau  traitement  des  p6rim£trites :  Comptes  Rendus  du  Congres  de  Copenhague,  Section 
d'Obstetrique  et  de  Gynecologic,  p.  141. 


654  APPENDIX. 

explain  some  of  the  terms  used,  so  that  students  may  read  straight  on 
without  the  interruption  of  consulting  books  on  electricity  which 
may  not  be  at  hand  at  the  time. 

Kinds  of  In  the  first  place,  there  are  two  distinct  kinds  of  electric  current 
Current  8P°ken  of,  the  Galvanic  (perhaps  more  accurately  the  "  Voltaic  ")  and 
the  Faradic.  The  former  is  the  electricity  that  flows  in  continuous 
current  through  the  wires  from  the  zinc  and  copper  plates  in  a  voltaic 
or  galvanic  cell  or  battery  when  their  ends  are  connected.  As  sulphuric 
or  other  oxidising  acid  is  added  to  the  water  in  the  cell,  this  kind  of 
current  is  chemical  in  its  origin.  When  the  current  flows,  the  zinc 
plate  is  used  up,  its  consumption  furnishing  the  energy  to  drive  the 
current  through  the  cell  and  connecting  wire  :  the  cell,  in  fact,  has 
been  aptly  compared  to  a  sort  of  chemical  furnace  in  which  the  fuel  is 
zinc.  The  faradic  current,  on  the  other  hand,  is  an  induction  one, 
i.e.,  is  a  current  induced  in  a  closed  circuit  when  a  magnet  is  moved 
near  it  or  when  it  is  moved  across  the  magnetic  field,  or  when  an 
electric  current  whose  strength  is  changing  is  near  it.  The  source  of 
this  current  is,  accordingly,  not  chemical  but  electro-magnetic. 
Electro-  That  which  tends  to  produce  a  current,  i.e.,  to  move  electricity  from 
one  P^ace  *°  another,  is  called  Electro-motive  force  ;  the  Strength  of  a 


Strength  of  Current  is  the  quantity  of  electricity  which  flows  past  any  point  of  the 
circuit  in  one  second,  and  is  directly  proportional  to  the  electro-motive 
force  and  inversely  proportional  to  the  resistance  which  the  current 
has  to  overcome  in  its  flow.  This  truth  with  regard  to  the  strength  of 
an  electric  current  flowing  in  a  circuit  is,  from  the  name  of  its 
discoverer,  known  as  Ohm's  Law,  which  may  be  formally  stated  here  — 
"  The  strength  of  the  current  varies  directly  as  the  electro-motive  force,  and 
inversely  as  the  resistance  of  the  circuit."  The  terms  "strong,"  "great," 
and  "intense,"  applied  to  currents  all  mean  the  same  thing. 
Measure-  To  measure  the  strength  of  electric  currents  there  is  used  an  instru- 
Strengthofmen^  ca^e(i  the  Galvanometer,  in  which  a  magnetised  needle  is  deflected 
Electric  by  a  current  passing  above  and  below  it  through  a  coil  of  silk-covered 
insulated  copper  wire  —  the  amount  of  deflection  depends  upon  the 
strength  of  the  current  (though  not  proportional  to  it)  and  a  properly 
graduated  dial  enables  us  to  ascertain  perfectly  the  strength  of  the 
current.  The  sensitiveness  of  the  instrument  is  greatly  increased  by 
the  use  of  the  astatic  needle,  a  compound  one  in  which  the  directive 
power  of  the  earth  is  neutralised  by  the  joining  of  two  magnetised 
needles  of  equal  power  connected  one  above  the  other  by  a  central 
pin  so  that  the  north  pole  of  the  one  lies  over  the  south  pole  of  the 
other  and  the  south  pole  over  the  north  pole  of  the  other.  The 
sensitiveness  is  also  increased  within  certain  limits  by  increasing  the 
number  of  turns  of  the  coil  of  silk-covered  wire.  A  galvanometer 
must  be  able  to  measure  the  quantity  of  electricity  passed,  and  should 


ELECTRICITY  IN  GYNECOLOGY.  655 

be  of  a  degree  of  sensitiveness  corresponding  to  the  strength  of  the 
current  to  be  measured — very  sensitive  for  very  small  currents,  less 
sensitive  for  strong  currents. 

UNITS  OF  MEASUREMENT. — Every  kind  of  measurement  requires  a 
unit :  as  in  measuring  length  we  might  take  the  inch,  foot,  yard,  or 
mile ;  and  in  measuring  mass  or  weight  we  use  the  grain,  ounce, 
pound,  hundred- weight,  or  ton.  Accordingly,  for  measuring  electricity, 
we  have  in  the  first  place  a  series  of  what  are  called  absolute  electric 
units  derived  from  the  fundamental  Centimetre-Gramme-Second  system 
(C.G.S.)  in  which— 

The  Centimetre  (-3937  in.)  is  the  unit  of  length, 
The  Gramme  (15'432  grns.)  is  the  unit  of  mass,  and 
The  Second  is  the  unit  of  time. 

There  are  three  derived  units  which  it  is  necessary  to  bear  in  mind  in 
order  to  understand  the  electric  units  which  follow.  These  are — 

The  Dyne  or  unit  of  force,  that  force  which  acting  for  one  second  on 
a  mass  of  one  gramme  gives  to  it  a  velocity  of  one  centimetre  per 
second ; 

The  Erg  or  unit  of  work,  the  work  done  in  overcoming  unit  force 
through  unit  distance,  i.e.,  in  moving  a  mass  through  a  distance  of  one 
centimetre  against  the  force  of  a  dyne  ;  and 

Unit  Strength  of  Magnetic  Pole. — The  unit  magnetic  pole  is  of  such  a 
strength  that  when  placed  at  a  distance  of  1  cm.  in  air  from  a  similar 
pole  of  equal  strength  it  repels  it  with  a  force  of  one  dyne. 

We  are  now  in  a  position  to  understand  the  definition  of  the  units 
referred  to  in  the  explanation  of  Apostoli's  method.  As  that  method 
deals  with  Current  Electricity  in  which  the  positive  and  negative  poles 
are  in  properties  the  same  as  magnetic  ones,  these  units  are  called 
Electro-magnetic. 

Electro-magnetic  Absolute  Units. — (1)  Unit  Strength  of  Current  is  that 
of  a  current  such  that  if  one  centimetre  length  of  its  circuit  be  bent  into 
an  arc  of  one  centimetre  radius  it  will  exert  a  force  of  one  dyne  on  a  unit 
magnet  pole  placed  at  the  centre  of  the  circle  of  which  the  arc  is  a  part, 
so  as  to  be  always  a  centimetre  away  from  the  current. 

(2)  Unit  Quantity  of  Electricity,  that  quantity  of  electricity  which  is 
conveyed  by  current  of  unit  strength  in  one  second. 

(3)  Unit  of  Difference  of  Potential  or  of  Electro-motive  Force  exists 
between  two  points  when  it  requires  the  expenditure  of  one  unit  of  work 
(Erg)  to  bring  a  unit  of  +  electricity  from  one  point  to  the  other  against 
the  electric  force. 

(4)  Unit  of  Resistance  is  possessed  by  a  conductor  when  unit  difference 
of  potential  between  its  ends  causes  a  current  of  one  unit  of  quantity 
per  second  to  flow  through  it. 


656  APPENDIX. 

The  first  two  of  these  absolute  units  were  found  to  be  inconveniently 
small  and  the  last  two  inconveniently  large,  accordingly  a  committee  of  the 
British  Association  devised  a  system  of  "practical"  units  in  which  they 
substitute  for  the  fundamental  units  centimetre  and  gramme,  the  Earth's 
quadrant  (1,000,000,000  centimetres)  and  TT7T7  ^cnjyffinr.Tnnj-  of  a  gramme. 

Electro-magnetic  Practical  Units. — (1)  The  Volt  x  is  the  practical  unit 
of  Electro-motive  force  and  is  100,000,000  absolute  units. 

(2)  the  Ohm  x  is  the  practical  unit  of  Resistance  and  is  1,000,000,000 
absolute  units. 

(3)  The  Ampere,1  the  practical  unit  of  Strength  of  Current,  is  that 
furnished  by  a  Volt  through  an  Ohm  and  is  -^  of  the  absolute  unit. 
In  medical  electricity,  however,  the  strength  of  the  current  is  measured 
in  milliamperes. 

(4)  The  Coulomb  x  is  the  practical  unit  of  Quantity  of  current  electricity 
and  is  -£$  of  the  absolute  unit. 

With  the  aid  of  these  units,  we  can  now  state  Ohm's  law  in  more 
definite  language,  using  "amperes"  to  measure  "strength  of  current," 
"volts"  for  "electro-motive  force,"  and  "ohms"  for  "resistance  of 
circuit."  Thus  the  two  forms  would  run  as  follows : — 

(General  Form.)  The  strength  of  the  current  varies  directly  as  the 
electro-motive  force  and  inversely  as  the  resistance  of  the  circuit ; 

(Definite  Form.)  The  number  of  amperes  of  current  is  equal  to  the 
number  of  volts  of  electro-motive  force,  divided  by  the  number  of  ohms 
of  resistance  in  the  circuit,  or  more  briefly 

The  number  of  amperes  is  equal  to  the  number  of  volts  divided  by  the 
number  of  ohms. 

More  than  one  method  has  been  tried  of  fixing  a  standard  for  these 
units.  Thus,  the  British  Association  (B.A.)  in  1863  constructed  coils 
of  German  silver  to  give  the  resistance  of  an  ohm,  but  there  was  some 
doubt  whether  the  B.A.  unit  exactly  represented  the  practical  unit  of 
resistance  as  defined  above.  Accordingly,  it  was  decided  at  the  Inter- 
national Congress  of  Electricians  in  Paris  in  1881  that  the  ohm  could 
be  most  accurately  measured  by  the  resistance  offered  to  the  electric 
current  by  a  column  of  pure  mercury  with  a  cross-section  of  one  milli- 
metre ;  and,  in  1884,  it  was  decided  at  the  Paris  Congress  that  the 
length  of  the  column  should  be  106  centimetres.  This  gives  almost 
exactly  2  the  theoretical  ohm,  and  is  a  little  larger  than  the  B.A.  unit/3 

In  concluding  this  note  on  the  electric  terms  used,  we  may  mention  that 
the  ends  of  the  wires  leading  from  the  battery  are  called  Electrodes  ;  that 
Electrolysis  (i.e.  Electric  Analysis)  is,  strictly  speaking,  the  process  of 

1  These  four  terms  commemorate  the  names  of  four  famous  electricians  -.—Alessandro  Volta,  who 
shares  with  Galvani  the  discovery  of  current  electricity  ;  G.  S.  Ohm,  whose  law  regulating  the 
strength  of  current  electricity  has  been  given  above  ;  Andri  Ampere,  the  founder  of  the  science  of 
electro-dynamics  ;  and  Charles  A.  de  Coulomb,  the  inventor  of  the  torsion  balance  and  demonstrator 
of  the  law  that  electrical  attraction  and  repulsion  vary  inversely  as  the  square  of  the  distance. 

2  Lord  Rayleigh  calculated  that  the  length  of  column  to  give  the  exact  ohm  should  be  106'21  cm. 

3  The  B.A.  ohm  is  "9887  of  the  new  legal  ohm  and  the  B.A.  volt  is  '9887  of  the  legal  volt. 


ELECTRICITY  IN  GYNECOLOGY.  657 

decomposing  a  liquid  by  means  of  an  electric  current,  but  is  also  applied 
to  the  disintegrating  process  said  to  be  set  up  in  tumours  or  other  tissues 
when  a  current  has  been  passed  through  them;  and  that  Apostoli 
describes  his  method  as  mono-polar  when  only  one  pole  is  active,  i.e.,  is 
applied  to  uterus,  vagina,  or  tissue  to  be  acted  upon,  and  as  bi-polar 
when  both  poles  are  so  applied. 

Apostoli  in  describing  his  application  of  the  faradic  current  uses  the 
old  phraseology  (employed  before  the  discovery  of  Ohm's  law)  when  he 
speaks  of  "  currents  of  quantity  "  and  "  currents  of  tension  "  or  "  inten- 
sity currents;"  meaning  by  the  former  a  current  flowing  through  a 
circuit  in  which  there  is  a  very  small  resistance  inside  the  battery1  or  in 
the  wire,  and  by  the  latter  a  current  which  has  to  overcome  greater 
resistance  and  which  requires,  therefore,  a  high  electro-motive  force.3 
These  terms  are  scientifically  misleading  as  the  great  resistance  tends  to 
counteract  the  high  electro-motive  power,  and  the  principal  phenomena 
of  electro-magnetism  are  due  not  to  the  mere  presence  of  electricity 
however  great  its  tension  but  to  its  state  of  current  or  flow.  The 
terms  are,  however,  convenient ;  and,  what  is  more  to  the  purpose  here, 
Apostoli's  whole  method  is  founded  upon  his  declared  discovery  that  the 
physiological  effects  of  currents  in  the  two  conditions  are  very  different. 

ACTION    OP   DIFFERENT    CURRENTS    AND    POLES. 

1.   Action  of  the  Galvanic  or  "  Galvano-camtic"  Current. 

For  this  current  Apostoli  claims  two  successive  and  distinct  effects : — 
(1)  A  chemical  (not  thermic)  cauterisation  at  points  of  entrance  and 
exit  of  the  current,  and  in  proportion  to  dose  and  duration ;  and  (2)  An 
interpolar  action,  through  the  entire  uterine  substance,  as  the  current 
passes  from  internal  to  external  pole. 

It  is  this  current  he  uses  in  the  treatment  of  Uterine  Fibromata;  and 
he  describes  his  method  as  "  galvano-caustic,  intra-uterine,  and  mono- 
polar."  The  current  is  used  in  various  forms,  as  will  be  seen  from  the 
summary  of  the  94  cases  fully  described  in  the  second  part  of  his 
memoir  of  1884  on  the  Treatment  of  Fibroid  Tumours  of  the  Uterus  : — 

In  59  cases,  the  galvano-caustic  current  with  positive  pole  active  was  used; 
»  21     ,,       „         „  „  „         „     negative   „       „        „      „ 

„    9     „       ,,         ,,  ,,  ,,         „     negative  and  positive    poles 

successively  active  was  used  ;  and 
,,    5     ,,          the  galvano-puncture  was  used,  preceded  or  followed  by 

1  The  internal  resistance  is  diminished  by  haying  larger  plates  or  bringing  them  closer  together  ; 
the  former  is  usually  done  by  connecting  the  zincs  of  several  cells,  producing  practically  one  large 
zinc,  and  the  same  for  the  coppers. 

1  Brit.  Med.  Jour. ,  1888, 1. ,  p.  64.  "  No  Apparatus  for  Faradisation,"  he  writes,  is  "  complete  with- 
out two  independent  bobbins  ;  which  according  to  the  length  and  thickness  of  the  wires  gives  currents 
differing  in  qualities  and  characters.  The  bobbin  with  short  thick  wire  gives  current  of  quantity 
because  the  wire  is  less  resistant  and  lets  pass  a  greater  volume  of  electricity.  The  bobbin  with 
longer  and  finer  wire  is  called  the  bobbin  of  tension ;  the  current  along  it  is  called  the  current  of 


2  T 


658  APPENDIX. 

positive   or  negative  intra-uterine  cauterisation.     The  effects  of  these 
various  forms  are  clearly  stated. 

a.  Effect  of  Galvano -caustic  current  with  POSITIVE  POLE  active. — The 
local  effect  of  the  positive  pole  is  said  to  be  coagulating  and  hardening. 
It  is  accordingly  to   be   the   active   intra-uterine  one  in  all  cases   of 
bleeding  fibromata  or  where  there  is  accompanying  obstinate  leucorrhoea. 
It  is  described  as  arresting  haemorrhage  instantly  if  the  cavity  of  the 
uterus   be   of  normal   dimensions,    the  action  relatively   intense,  and 
haemorrhage  not  excessive ;   otherwise,  it  acts   more  deliberately  and 
gradually. 

b.  Effect  of  Galvano- caustic  current  with  NEGATIVE  POLE  active. — This 
pole  is  declared   to   produce  a  state   of  temporary  congestion  without 
direct  haemostatic  effect.     The  interstitial  circulation  of  the  uterus  is  thus 
temporarily  stimulated  and  hurried  on.     Therefore,  a  regression  of  non- 
hcemorrhagic  fibromata  results,  either  from  the  congestion  or  the  supple- 
mentary artificial  and  subsidiary  haemorrhages.     This  pole,  therefore,  is 
to  be  used  for  fibroids  accompanied  by  amenorrhcea  or  dysmenorrhcea. 
In  inducing  a  regression  of  the  tumour  by  the  secondary  interstitial 
changes  from  interpolar  action,  Apostoli   believes   that  the  negative 
pole  is  the  more  powerful.     Further,  if  the  negative  pole  be  made  to 
enter  by  puncture  into  the  substance  of  the  fibroid  deposit,  it  "  becomes 
by  '  a  sort  of  contre-coup '  markedly  haemostatic  due  to  its  cutting  off  the 
supplementary  circulation  by  the  rapid  atrophy  the  'negative  current 
causes." 

c.  Effect  of  Galvano-puncture. — This  form  of  application  is  said  to  be 
daily  assuming  more  importance.     It  is  indicated  necessarily  in  xiterine 
atresia,   or  where  there  is  such  uterine  displacement  as  to  prevent  the 
introduction  of  a  sound.     It  is  to  be  preferred  where  the  puncturing  can 
be  combined  with  intra-uterine  cauterisation  to  hasten  and  make  sure 
of  the  desired  effects.     The  chief  points  in  the  method  of  applying  this 
treatment  are : — 

(1)  Antiseptic  irrigation  of  Vagina  ; 

(2)  Make  punctures  shallow,  not  deeper  than  1-2  cm. ; 

(3)  Make  puncture  on  most  prominent  part  of  fibroid,   where 

possible  in  posterior  cul-de-sac  ; 

(4)  Make  punctures  without    speculum,    slide    trocar    through 

sheath  after  having  chosen  by  touch  the  point  where  the 
puncture  is  to  be  made  ; 

(5)  Ascertain  any  seat  of  pulsation  so  as  to  avoid  wounding  an 

important  vessel ; 

(6)  In   case   of  any  unusual  haemorrhage,   immediately   dilate 

vagina  with  an  expanding  speculum  and  if  necessary  apply 
a  pressure-forceps  to  the  bleeding  point. 


ELECTRICITY  IN  GYA 'ECOLOGY.  659 

"No  operator,"  Apostoli  adds,  "should  admit  the  failure  of  intra- 
uterine  galvano-cauterisation  before  having  had  recourse  to  the  galvano- 
punctures,  which  he  must  enforce  either  with  or  without  anaesthetics."  1 

2.  Action  of  the  Faradic  or  Induced  Current. 

This  current  is  said  to  have  "  contractile  power "  but  its  effects 
differ  as  the  "  current  of  quantity  "  or  the  "  current  of  tension  "  is  used. 
The  former,  the  direct  excitant  of  muscular  contractility,  is  employed 
to  overcome  uterine  muscular  inertia  and  produce  a  temporary  vascular 
activity ;  it  thereby  excites  circulation  where  there  is  congestion  and 
stagnation  with  consequent  arrest  of  the  nutrition  of  the  uterus.  The 
"  current  of  tension  "  acts  more  on  the  sensibility  than  on  the  muscular 
contractility ;  it  has  therefore  been  used  in  all  cases  where  pain  is  the 
leading  symptom.  "  No  other  sedative,  recognised  in  Gynecology,  for 
the  purpose  we  are  treating  of,  equals  the  faradic  current  of  tension." 
Certain  rules  are  laid  down  for  the  application  of  this  current  which 
are  declared  to  be  essential  to  its  use,  and  which  will  be  found  below.2 
This  treatment  Apostoli  strongly  recommends  forperimetritis,  ovarian  pain, 
and  intense  sensibility  about  the  lower  part  of  the  vagina.  As  a  whole, 
the  induced  current  is  a  direct  excitant  of  muscular  fibre.  Where  the 
mucous  membrane  is  at  fault  as  in  endometritis,  there  is  nothing  on 
which  it  can  act  curatively,  and  the  constant  or  galvanic  current  is  the 
remedy. 

THE    APPARATUS    AND    INSTRUMENTS. 

1.  For  the   Use  of  the   Galvanic  Constant   Current.^  —  (1)    The   first  Apparatus 
requisite  is,  as  Apostoli  puts  it,  some  sort  of  a  battery  capable  of  yielding  ments. 
an  adequate  constant  current  of  electricity,  i.e.,  one  rising  from  10  to 
about  300  milliamperes ;   and  it  should  be  provided  with  a  regulator 
by  which  the  circuit  is  made  to  include  any  number  of  cells  desired, 
as  well  as  with  a  Current  Interrupter  4  and  a  Commutator  or  Current 
Reverser. 5 

(2)  The   second   requisite   is    a   good  galvanometer   "  of  intensity," 
i.e.,  able  to  measure  a  current  of  considerable  strength,  the  graduation 
being  extended  up  to  250  amperes  at  least.     Keith  uses  Gaiffe's  instru- 
ment. 

(3)  The  next  portion  of  the  apparatus  to  be  considered  is  the  intra- 
uterine  electrode.     In  form  it  is  like  a  uterine  sound,  straight  or  only 
slightly  curved,  and  long  enough  to  reach  the  fundus  of  an  enlarged 
uterus.     The  positive  pole  corrodes  all  metals  except  gold,  aluminium, 

1  The  Dublin  paper  of  1887  :  see  Brit.  Med.  Jour.,  1887,  II.,  pp.  700-701. 

2  "On  Some  New  Applications  of  the  Induced  or  Faradic  Current  in  Gynecology,"  by  Apostoli, 
Brit.  Med.  Jour.,  1888,  I.,  p.  63. 

*  Brit.  Med.  Jour.,  1887,  II.,  700.     See  also  Woodham  Webb  on  the  "Treatment  of  Fibroids  of 
the  Uterus  by  Electricity  :  the  Apparatus  and  Instruments" — ibid.,  1887,  I.,  p.  1208. 

*  Sometimes  called  a  "  Kheotome."  5  Sometimes  called  a  "  Rheotrope." 


660  APPENDIX. 

and  platinum  ;    and   it   is  found  that  platinum  is  the  material  best 
adapted  for  this  purpose.     Carbon  is  also  very  good. 

(4)  Very  important  is  the  inoffensive  cutaneous  electrode  of  wet  potter's 
earth,  spread  out  in  a  layer  half-an-inch  thick  and  covering  the  lower 
part  of  the  abdomen.     This  is  said  to  be  the  master  point  of  this  method 
of  treatment,   as  it  enables  strong  currents  to  be  employed  without 
injury  to  the  skin  which  would  be  cauterised  were  the  external  electrode 
of  the  same  small  area  as  the  internal. 

(5)  For  the  galvano-punctures  there   is  required  a  steel  trocar  or 
needle. 

2.  For  the  Faradic  or  Induced  Current. — (1)  The  first  requisite  here  is 
a  faradic  battery. 

(2)  A  special  form  of  sound,  for  Apostoli  uses  the  bi-polar  method 
for  the  faradic  current.  Accordingly,  the  sound  contains  both  poles 
side  by  side  within  its  substance,  so  that  the  circuit  may  be  closed 
within  the  uterus  (if  that  be  possible)  or  vagina. 

THE  CURRENT:  ITS  STRENGTH,  DURATION,  AND  FREQUENCY  OF  OPERATION. 

For  the  galvanic  current,  Apostoli  repeatedly  insists  that  it  is 
virtually  a  uterine  cauterisation,  in  which  the  highest  possible  degree 
of  electro-chemical  action  is  used,  and  that  the  current  must  be  con- 
tinuous without  any  interruption  during  the  operation.  As  to 
the  strength  of  the  charge,  his  absolute  rule  is  that  it  be  exactly 
measured,  and  that  it  be  as  great  as  the  patient  can  bear  up  to  what 
the  desired  effect  requires :  the  range  attainable  is  as  high  as  300  mil- 
liamperes.  The  duration  of  the  application  necessary  to  produce  effec- 
tive cauterisation  is  on  an  average  from  five  to  eight  minutes.  In 
Keith's  106  cases,  five  minutes  was  by  far  the  most  common  duration. 
The  number  of  applications  required  to  produce  good  results  varies  with 
different  patients,  according  to  the  nature  of  the  disease  and  the  object 
sought  for.  In  Apostoli's  treatment  of  fibroids  the  average  was  over 
fifteen  per  patient.  In  Keith's  cases,  they  sometimes  number  more  than 
fifty,  and  were  made  usually  daily  or  every  alternate  day  except  during 
the  menstrual  period. 

The  place  of  application  must  also  be  strictly  localised,  and  this  is 
ensured  by  the  method  being  intra-uterine  mono-polar. 

Principles  are  also  laid  down  governing  the  application  of  the  faradic 
current.  The  strength  varies  within  the  extreme  known  limits.  In 
such  inflammatory  conditions  as  perimetritis,  and  above  all  in  acute  cases, 
the  rule  is  to  begin  with  a  very  small  dosage  and  increase  milliampere 
by  milliampere  as  the  power  of  endurance  increases  and  the  phlegmasia 
shows  a  tendency  to  give  way.  In  using  this  current  for  ovaralgia, 
however,  the  direction  is  to  press  boldly  forward  if  the  uterine  region  be 
healthy :  for  the  relief  of  pain,  the  application  is  not  to  end  even  after 


ELECTRICITY  IN  GYNECOLOGY.  661 

twenty  minutes  till  the  pain  has  disappeared  ;  generally  the  first  sitting 
requires  most  time,  the  subsequent  ones  only  completing  what  it  has 
begun.  These  applications  of  the  faradic  current  should  follow  each 
other  every  day  or  even  twice  a  day.  The  number  of  sittings  varies  : 
from  two  to  five  are  said  to  be  sufficient  for  simple  neuralgia,  but  the 
range  is  much  greater  for  inflammation. 

PATHOLOGICAL  CONDITIONS  IN  WHICH  ELECTRICITY  IS  USED  IN  GYNECOLOGY. 

In  the  opening  historical  paragraph  of  this  brief  sketch  of  Apostoli's  Conditions 
method,  it  will  be  seen  that  he  has  published  special  papers  on  the 


treatment   of   fibroid   tumours   of   the   uterus,    chronic    metritis   andisusedm 
endometritis,  perimetritris,  localised  inflammation  of  the  vagina,  hydro-  oology. 
salpinx  and  salpingitis  ;  and  he  says  that  he  has  applied  the  continuous 
galvanic  current  for  most  of  the  maladies  known  to  Gynecology. 

So  far  as  our  present  knowledge  goes,  the  suitable  cases  for  Apostoli's 
method  are  — 

1.  Bleeding  Fibroids.  —  In  these  the   internal  pole  is  positive,  and  a 
current  strength  of  50  to  150  ma.  may  be  used. 

2.  Impacted  or  large  Fibroids  causing  pressure  symptoms.  —  Puncture 
here  with  negative  needle. 

3.  Dysmenorrhoea    of  pathological    anteflexion  :    membranous    dysmen- 
orrhoea.  —  Internal  electrode  negative,  and  current  strength  about  50  ma. 

4.  Cellulitis.  —  Internal  electrode  covered  with  cotton  wool  and  placed 
vaginally. 

5.  Pain,    ovarian.  —  Here  the  faradic  current  is  said  to  give   good 
results. 

We  say  nothing  here  in  the  way  of  describing  instruments  or  details 
of  treatment.  We  may  say,  however,  that  we  have  found  as  an  abdo- 
minal electrode  Engelmann's  broad  plate  with  cotton  wool  soaked  in 
salt  solution  quite  as  good  as  and  much  more  convenient  than  potter's 
clay. 

RESULTS. 

The  results  claimed  for  this  method  in  the  treatment  of  tumours  of  Results. 
the  uterus  have  already  been  given  (p.  429)  —  "in  every  case,  the  tumour 
was  reduced  in  size,  haemorrhage  and  pain  gone,  and  general  health 
restored."  The  Keiths  state  in  the  introduction  to  their  book  that 
they  now  know  that  cases  with  haemorrhage  are  the  best  for  treatment, 
and  admit  that  in  their  series  of  cases  there  are  some  imperfect  and 
incomplete  ones,  but  repeat  their  confidence  in  the  immense  utility  and 
ultimate  triumph  of  the  method.  Cases  of  enlargement  of  the  uterus 
have  every  one  been  perfectly  cured.  Similarly  good  results  are  claimed 
in  other  affections. 


662  APPENDIX. 


THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION. 

LITERATURE. 

Bramwell,  Byrom—The  Diseases  of  the  Spinal  Cord  :  Edin.  1882.  Gaskell—  Preliminary 
Notice  of  Investigation  on  the  Action  of  the  Vasomotor  Nerves  of  Striated  Muscle  : 
Proc.  Roy.  Soc.,  Lond.,  1876-7,  p.  430.  Goodell — Lessons  in  Gynecology,  Lesson 
XXX.  :  Philadelphia,  1880.  Mitchell,  Weir— Fat  and  Blood,  and  how  to  make 
them :  Lond.,  1878.  Play  fair,  W.  £—  The  Systematic  Treatment  of  Nerve  Pro- 
stration and  Hysteria :  Lond.,  1883. 

The  gynecologist  will  not  have  long  practised  his  specialty  before  he 
finds  that  he  has  occasionally  to  deal  with  a  class  of  patients  who  are 
quite  sui  generis.  The  condition  of  such  puzzles  him  at  first  extremely, 
inasmuch  as  he  can  find  no  tangible  disease  but  yet  is  bound  to  confess 
that  the  general  condition  of  health  is  highly  unsatisfactory.  Very  often 
these  patients  have  gone  the  round  of  all  medical  and  surgical  specialists, 
and  have  come  at  last  to  the  gynecologist  in  the  hope  that  his  art  may 
do  something  to  remedy  their  lamentable  state. 

The  class  of  patients  has  the  following  characteristics : — They  are 
thin,  often  emaciated,  unable  for  any  exertion,  suffer  from  neuralgia, 
have  little  or  no  appetite,  and  are  nursed  by  some  devoted  sister  or 
mother  or  husband.  As  we  have  said,  there  is  no  local  condition  to 
account  for  their  state  ;  but  often  there  is  a  history  of  overwork,  as  in  the 
case  of  governesses  and  teachers,  or  of  an  improper  training.  By  this 
latter  we  mean  that  a  sensitive  child  of  high  nervous  organisation  has 
been  over-cultivated,  her  mental  energies  too  constantly  on  the  rack, 
and  has  ultimately  collapsed  under  the  strain.  For  this  class  of  patients 
Weir  Mitchell  of  Philadelphia  introduced  a  plan  of  treatment  in  his 
well-known  book,  the  results  of  this  method  being  in  suitable  cases 
highly  satisfactory. 

The  main  factors  in  Weir  Mitchell's  plan  are — 

I.  Seclusion  of  the  patient,  and  absolute  exclusion  of  all  but  the 

medical  attendant  and  nurse  ; 
II.  Absolute  Rest  in  Bed  ; 

III.  A  Systematic  extra-feeding  of  the  patient ; 

IV.  Use  of  Massage  and  Electricity. 

I.  Seclusion  of  the  patient,  and  absolute  exclusion  of  all  but  the 
medical  attendant  and  nurse. 

This  is  imperative,  and  the  treatment  should  not  be  gone  on  with 
unless  this  condition  is  agreed  to  absolutely.  Very  often  the  friends 
have  devoted  themselves  to  every  whim  and  fancy  of  the  patient  so 
assiduously  as  to  impair  their  own  health  without  improving  that  of 
their  tyrannous  charge. 


TREATMENT  OF  NERVE  PROSTRATION.  663 

The  nurse  should  be  thoroughly  trained  and  refined,  and  should 
implicitly  obey  all  the  medical  attendant's  orders. 

II.  Absolute  rest  in  bed. 

This  means  muscular  and  mental  rest,  and  reduces  the  force  and  fre- 
quency of  the  heart's  action.  The  nutrition  taken  is  above  the  amount 
worked  off,  and  benefit  in  this  way  results.  This  absolute  rest  is  after  a 
while  modified,  and  the  patient  allowed  to  sit  up  for  a  little  until  she 
may  at  length  go  about  as  usual,  with  the  exception  of  taking  a  two- 
hours'  sleep  during  the  day. 

III.  A  systematic  extra-feeding  of  the  patient. 

This  is  one  of  the  essential  features  of  the  method.  Weir  Mitchell 
begins  with  milk  diet,  about  three  ounces  every  two  hours,  until  two 
quarts  are  given  during  the  day.  At  the  end  of  the  first  week  raw 
beef  soup1  is  given,  and  gradually  the  diet  is  increased  until  the  dietary 
for  one  day,  in  one  of  Mitchell's  cases,  was  as  follows  : — Coffee  at  7 ;  at 
8,  iron  and  malt.  Breakfast — a  chop,  bread  and  butter,  of  milk  a 
tumbler  and  a  half;  at  11,  soup;  at  2,  iron  and  malt.  Dinner 
(closing  with  milk,  one  or  two  tumblers)  consisted  of  anything  she 
liked,  and  with  it  she  took  about  six  ounces  of  Burgundy  or  Dry 
Champagne.  At  4,  soup.  At  7,  malt,  iron,  bread  and  butter,  and 
usually  some  fruit,  and  commonly  two  glasses  of  milk.  At  9,  soup ; 
and  at  10,  her  aloes  pill.  At  noon,  massage  occupied  an  hour.  At  4.30 
p.m.,  electricity  was  used  for  an  hour." 

In  addition  to  this  diet,  iron  in  the  form  of  Blaud's  pills  (p.  583)  and 
maltine  may  be  added  to  aid  the  digestion  of  starchy  food.  The  maltine 
should  be  given  in  cold  milk  or  at  the  end  of  pudding.  The  evident 
question  now  arises,  How  does  the  patient  digest  all  this  1  The  diges- 
tion of  this  immense  mass  of  food  is  rendered  possible  by  the  last  feature 
of  the  treatment. 

IV.  The  use  of  Massage  and  Electricity. 

This  is  most  important,  and  consists  in  the  systematic  rubbing  of  the 
patient  and  the  application  of  Faradic  electricity. 

The  massage  is  begun  a  few  days  after  the  milk  diet,  and  consists  in 
the  systematic  kneading  of  the  skin  and  muscle  of  the  whole  body  first 
for  half-an-hour,  and  afterwards  for  an  hour  daily.  A  special  massage 
nurse  is  necessary  for  this,  and  it  should  be  kept  up  for  six  or  seven 
weeks.  Cocoa-nut  oil  should  be  used  to  render  the  manipulations  easy, 
and  it  will  also  help  in  fattening  the  patient. 

Electricity  is   employed   for   half-an-hour   daily  in   order   to   cause 

1  Chop  1  Ib.  of  raw  beef,  and  place  in  a  bottle  with  1  pint  of  water  with  5  mm.  strong  hydro- 
chloride  acid.  Place  in  ice  all  night,  and  in  the  morning  set  in  a  pan  of  water  at  110°  Fahr.  for 
2  hours.  Strain  thoroughly,  and  give  filtrate  in  portions  daily. 


664  APPENDIX. 

muscular  action,  increase  the  blood  supply  to  the  muecle,  and  act  as  a 
tonic  and  bracing  agent.  Mitchell  has  found  that  after  the  electricity 
the  temperature  usually  rises  about  |ths  of  a  degree.  The  cm-rent 
should  not  be  painful,  and  Ziemssen's  diagrams  of  the  points  of  stimula- 
tion should  be  followed  as  a  guide. 

For  further  details,  the  literature  given  should  be  consulted  by  the 
practitioner  wishing  to  carry  it  out. 

The  results  in  some  cases  are  wonderful,  and  as  yet  no  harm  has  been 
shown  to  arise  to  the  kidneys  from  the  over-feeding.  The  bowels  must 
of  course  be  regulated,  and  a  daily  motion  secured.  Before  beginning 
this  treatment  in  any  case,  it  should  be  thoroughly  ascertained  that 
there  is  no  organic  disease,  and  no  obscure  and  rare  form  of  disease  such 
as  Addison's  disease,  myxcedema,  etc.  A  consultation  with  a  specialist 
should  always  be  had  in  cases  of  doubt. 

The  patient  for  whom  it  is  suitable  is  one  where  there  has  been 
under-feeding  or  improper  food,  undue  mental  strain,  and  consequent 
loss  of  flesh  and  nervous  energy. 

HYSTERIA    AND    HYSTERO-EPILEPSY. 

LlTERATUBK.  Bourneville  ct  Reynard — Iconographie  photographique  de  la  Saltpetriere  : 
Paris,  1877.  Bourneville  et  d'Oliei — Kecherches  sur  1'Epilepsie,  I'Hysterie  et 
1'Idiotie  :  Progres  Medical,  1881.  Charcot — Diseases  of  the  Nervous  System : 
Sydenham  Society's  Series,  London,  1877.  Fritsch — Krankheiten  der  Frauen : 
Braunschweig,  1881.  Jolly — Article  ' '  Hysteria  "  in  Ziemssen's  Cyclopaedia  of  Medi- 
cine. Mills — Hystero-epilepsy  :  American  Journal  of  the  Medical  Sciences,  Oct. 
1881.  Richer — Etudes  cliniques  sur  1'HysteVo-Epilepsie  :  Paris,  1881. 

HYSTERIA. 

The  frequency  of  hysteria  as  a  complication  of  pelvic  disease  requires 
that  we  notice  it  briefly.  We  can  only  indicate  the  leading  points  and 
refer  the  student  to  the  literature  given  above.  The  connection  which 
exists  between  hystero-epilepsy  and  the  ovary  also  calls  for  short 
reference. 

As  to  the  pathological  changes  present  in  hysteria,  little  definite  is 
known,  except  what  Freund  has  described  in  Parametritis  chronica 
atrophicans  (v.  p.  174).  In  regard  to  etiology,  we  note  first  the  influ- 
ence of  heredity  ;  defective  moral  education  by  a  hysterical  mother,  and 
the  power  of  imitation  in  developing  hysteria,  confirm  this  influence. 
A  reduced  state  of  the  system  is  also  a  very  important  cause,  and  the 
one  to  which  treatment  must  be  specially  directed.  As  to  the  exciting 
causes  usually  given  (such  as  dysmenorrhoea,  uterine  displacements, 
ovaritis),  these  are  so  common  that  we  cannot  regard  them  as  a  cause 
of  hysteria.  The  only  ascertained  facts  are  that  removal  of  the  ovaries 
has  in  some  cases  cured  hysteria,  and  that  pressure  in  an  ovarian  region 
does  sometimes  inhibit  a  hystero-epileptic  attack. 


HYSTERIA.  665 

The  symptoms  of  hysteria  are  protean.  Sensation  is  affected  as 
follows.  There  may  be  increased  sensitiveness  to  touch  (hypersesthesia) 
and  to  pain  (hyperalgesia).  Hypersesthesia  of  the  joints  is  important 
as  simulating  arthritis,  from  which  it  is  diagnosed  by  the  fact  that  the 
pain  is  around  (not  in)  the  joint  and  that  it  is  not  aggravated  on  forcing 
the  articular  surfaces  together.  Neuralgia  along  the  spine  with  tender 
points  simulates  disease  of  the  vertebral  column.  The  typical  headache 
(known  as  the  "  clavus  hystericus "  from  the  localised  and  intense 
character  of  the  pain),  neuralgia  of  the  muscles  generally,  localised  pain 
in  the  breast,  in  one  ovarian  region,  in  the  bladder  and  urethra,  and  the 
perversions  of  the  special  senses  need  only  be  mentioned  here.  When 
sensitiveness  is  impaired,  it  is  usually  that  to  pain ;  while  that  to  heat 
and  touch  remains ;  one  half  of  the  body  may  be  affected,  or  isolated 
portions  of  skin — as  the  back  of  the  hands  and  feet.  Loss  of  the 
muscular  sense  prevents  the  patient,  if  the  eyes  be  closed,  from  know- 
ing what  movements  she  has  made.  Anaesthesia  of  any  of  the 
mucous  membranes  may  occur.  The  special  senses  are  often  also 
impaired. 

The  motor  disturbances  resulting  in  convulsions  will  be  referred  to 
under  hystero-epilepsy.  The  paralysis  due  to  hysteria  is  very  import- 
ant in  regard  to  its  diagnosis  from  that  due  to  a  cerebral  or  spinal  lesion. 
It  varies  in  distribution  and  may  affect  one  limb  only,  or  the  arm  and 
leg  of  one  side,  or  the  arm  on  one  side  and  the  leg  on  the  other.  In  the 
face,  the  levator  palpabrse  superioris  is  frequently  affected ;  paralysis  of 
the  muscles  supplied  by  the  facial  and  hypoglossal  nerves  is  rare.  This 
last  fact  is  of  value  in  diagnosing  between  hysteria  and  hemiplegia ; 
further,  gradual  onset,  presence  of  anaesthesia  and  its  varying  distribu- 
tion, normal  reaction  to  the  electric  current,  the  progress  of  the  case 
with  variations  in  the  degree  and  extent  of  the  paralysis,  warrant  us 
in  diagnosing  hysteria.  The  diagnosis  of  hysterical  paraplegia  from 
multiple  sclerosis  is  more  difficult.  Paralysis  may  also  affect  the 
laryngeal  muscles,  producing  aphonia,  and  the  muscular  wall  of  the 
oesophagus,  stomach,  and  intestines. 

Of  the  disturbances  of  the  circulatory  system,  the  most  important  is 
palpitation  with  increased  force  of  the  apex  beat ;  in  some  cases,  the 
heart's  action  fails  and  there  is  syncope.  Vaso-motor  disturbances  are 
seen  in  the  pale  skin  which  does  not  bleed  when  pricked,  and  in  the 
flushings  and  profuse  sweatings  which  are  often  present.  Salivation  and 
polyuria  often  occur  after  a  hysterical  attack. 

In  forming  a  diagnosis,  we  must  be  careful  to  exclude  the  possibility 
of  organic,  cerebral,  or  spinal  disease.  A  case  reported  by  Bruce1 
is  of  interest  in  this  connection ;  here  the  patient  had  symptoms  of 
hysteria,  there  was  no  optic  neuritis  or  other  indication  of  cerebral 

1  Brain,  part  XXII. :  1883. 


666  APPENDIX. 

mischief,    and   yet   the   post-mortem  showed  a  large   tumour   in   the 
temporo-sphenoidal  lobe. 

In  treatment,  the  following  points  are  of  importance.  Care  must  be 
taken  in  the  mental  and  moral  training  of  the  children,  where  there  is  a 
tendency  to  hysteria.1  If  the  system  is  below  par,  Weir  Mitchell's 
method  should  be  tried,  and  iron  given  when  there  is  anaemia;  cold 
baths  are  always  beneficial.  In  grave  cases,  Battey's  or  Tait's  operation 
may  be  suggested  but  never  urged,  as  the  results  are  not  brilliant. 

HYSTEBO-EPILEPSY. 

This  term  is  applied  to  attacks  which  present  at  once  the  features  of 
hysteria  and  epilepsy;  they  are  also  described  by  Charcot  as  Grave 
Hysteria  or  Hysteria  Major.  The  standard  work  on  this  subject  is  by 
Richer ;  the  English  reader  will  find  a  good  account  of  it  in  the  paper 
by  Mills,  cited  above,  in  which  he  gives  (with  the  description  of  two 
cases  observed  by  himself)  the  results  of  the  valuable  researches  of 
Charcot,  Bourneville  and  Regnard,  and  Richer. 

Hystero-epilepsy  is  rare  in  this  country.  We  have  seen  one  case  in 
which  it  was  present  in  a  modified  form.  The  seizures  consisted  in 
regular  movements  of  the  lower  limbs,  so  that  the  patient  performed  a 
sort  of  dance  till  she  sank  down  exhausted ;  pressure  on  the  ovary 
checked  the  attack. 

A  typical  attack  is  divided  by  Richer  into  four  periods:  (1)  the 
epileptoid  period ;  (2)  the  period  of  contortions  and  great  movements ; 
(3)  the  period  of  emotional  attitudes ;  (4)  the  period  of  delirium. 

For  some  days  before  an  attack,  prodromic  symptoms  occur  in  the  form 
of  the  varying  symptoms  of  hysteria  given  above.  Charcot2  has  drawn 
attention  to  the  occurrence  of  acute  pain  or  sensitiveness  to  pressure  in 
one  ovarian  region  as  forming  the  starting  point  of  the  aura  hysterica ; 
slight  pressure  in  one  ovarian  region  will,  in  some  cases,  excite  an 
attack.  In  other  cases,  different  hypersesthetic  areas  have  been  local- 
ised, the  touching  of  which  produces  an  attack.  These  areas  are  known 
as  hystero-epileptogenic  zones  and  are  analogous  to  the  epileptogenic 
zones  described  in  epilepsy  by  Brown  Sequard.  During  the  epileptoid 
period  there  is  complete  loss  of  consciousness ;  further  there  is  (as  in 
true  epilepsy)  a  tonic  phase,  a  clonic  phase,  and  a  phase  of  resolution ; 
it  lasts  several  minutes.  It  is  important  to  note  that  there  is  loss  of 
consciousness  in  grave  hysteria,  as  the  absence  of  this  in  ordinary 
hysterical  convulsions  is  one  of  the  features  by  which  the  latter  are 
diagnosed  from  an  epileptic  attack.  The  contortions  and  great  move- 
ments of  the  second  period  differ  from  those  of  the  first  period  in  this 
that  the  muscles  are  quite  relaxed  apart  from  the  contortions ;  there  is 

1  Clouston:  Puberty  and  Adolescence  medico-psychologically  considered  :  Edin.,  1880. 
1  Lectures  on  Diseases  of  the  Nervous  System :  Sydenham  Translations,  1877,  p.  2(52. 


MASSAGE.  667 

no  tetanus.  Consciousness  is  not  lost.  The  whole  body  may  be  rolled 
about,  as  if  the  patient  were  writhing  in  pain ;  or  more  regular  move- 
ments occur,  e.g.,  the  movements  of  "salutations  "  in  which  the  patient, 
lying  with  the  knees  bent  up,  suddenly  throws  the  head  and  chest 
forwards  so  that  the  forehead  strikes  the  knees  and  then  falls  back 
again.  The  emotional  attitudes  of  the  third  period  are  beautifully  illus- 
trated by  a  series  of  photographs  in  Bourneville  and  Regnard's  work. 
Ecstacy,  irony,  disdain,  terror,  and  other  emotions  are  seen  on  the  face, 
and  the  attitude  of  the  body  corresponds  to  the  expression.  Hallucina- 
tions are  present,  and  the  patient  remembers  these  afterwards ;  volun- 
tary motion  is  unaffected,  but  general  and  special  sensibility  are  com- 
pletely suspended.  This  period  lasts  from  a  few  minutes  to  a  quarter  of 
an  hour.  The  fourth  period  is  not  sharply  marked  off'  from  the  preceding 
one.  The  patient  partially  recovers  consciousness  and  is  influenced  by 
external  impressions,  but  these  are  largely  mixed  with  hallucinations. 

A  succession  of  hystero-epileptic  attacks  produces  the  hystero-epileptic 
status  which  is  diagnosed  from  the  status  epilepticus  by  the  important 
fact  (ascertained  by  Charcot)  that  there  is  no  rise  of  temperature 
during  it. 

As  to  prognosis,  it  is  less  grave  than  in  true  epilepsy. 

As  to  treatment,  pressure  on  the  ovaries  often  checks  the  attack  at 
once ;  place  the  patient  on  the  back  and  forcibly  press  the  fist  into  the 
iliac  region.  Inhalation  of  chloroform  or  nitrite  of  amyl,  and  the  sub- 
cutaneous injection  of  morphia  are  also  valuable.  For  the  treatment  by 
electricity  and  metallo-therapy,  we  refer  the  practitioner  to  Richer's 
work.  Moral  discipline  is  specially  valuable. 

MASSAGE. 

LITERATURE.  Profanter—  (1)  Die  Massage  inder  Gynakologie ;  (2)  DieManuelle  Behand- 
lung  des  Prolapsus  Uteri :  Wien,  1888.  Reibmayr—Die  Massage :  Leipzig,  1889. 
Resch — Uber  die  Anwendung  der  Massage  bei  Krankheiten  der  weiblichen  Sexual- 
organe :  Cent,  fur  Gynak.,  No.  32,  1887.  See  also  Index  of  Literature  in  Appendix. 

One  of  the  most  common  cases  in  Gynecology  is  that  where,  as  the 
result  of  a  previous  attack  of  pelvic  inflammation,  the  uterus  and 
ovaries  are  bound  down  and  fixed  by  more  or  less  dense  adhesions — 
usually  peritonitic.  For  these  cases  many  forms  of  treatment,  ranging 
from  the  hot  douche  up  to  abdominal  section,  are  recommended,  and 
will  be  found  described  in  various  parts  of  this  Manual.  At  present  we 
wish  briefly  to  refer  to  a  method  of  treatment  recently  come  into 
vogue — Massage. 

By  this  we  mean  here  Bimanual  Massage  of  the  adherent  tissues  or 
organs  so  as  to  slacken  these,  promote  vascular  and  lymphatic  absorp- 
tion, and  in  this  way  bring  about  a  more  healthy  condition  of  the  local 


668  APPENDIX. 

circulation  and  relief  to  the  nerve  pressure  supposed  to  be  exerted  by 
the  cicatricial  tissues. 

The  originator  of  this  form  of  treatment  is  a  Swedish  layman, 
Brandt,  and  his  work  has  been  taken  up  by  several  German  gyne- 
cologists, among  whom  are  Schultze,  Profanter,  Schauta,  and  others. 

Before  going  on  more  particularly  to  the  question  of  indications, 
methods,  and  results,  we  may  say  that  we  believe  there  are  great 
difficulties  in  the  way  of  its  general  acceptance.  The  chief  one  is  that 
it  involves  undue  manipulation  of  the  genital  organs.  This  is  a  most 
serious  objection,  and  one  which  will  in  all  probability  be  fatal  to  the 
method.  Then  again  the  manipulation  will  be  dangerous  if  the  diag- 
nosis be  wrong — e.g.,  if  a  pyosalpinx  be  chosen  for  it.  There  is  thus 
every  prospect  of  its  being  supplanted  in  the  few  cases  requiring  it  by 
abdominal  section. 

Prolapsus  uteri  is  one  of  the  cases  specially  recommended  for  it. 
Here,  however,  it  is  difficult  to  understand  how  it  does  good,  although 
trustworthy  observers  have  recorded  cases  of  cure. 

Indications.  Retroversion  of  uterus  bound  down  by  adhesions  ;  adher- 
ent ovaries ;  parametritis  posterior  causing  pathological  anteflexion ; 
prolapsus  uteri. 

Methods.  In  chronic  inflammatory  cases  the  patient  occupies  the 
dorsal  posture,  with  knees  well  drawn  up  and  dress  freely  loosened. 
The  gynecologist  carefully  ascertains  bimanually  the  condition  of  the 
organs,  and  then,  keeping  the  two  fingers  passed  into  the  vagina  fixed,  he 
grasps  or  maps  out  by  the  outer  hand  the  adhesions  to  be  stretched,  and 
by  movement  of  the  outer  hand  only,  stretches  these  or  exercises  a 
rubbing  movement  on  them.  Rectal  manipulation  may  be  employed 
instead  of  vaginal.  This  bimanual  massage  should  not  be  practised  for 
more  than  a  few  minutes  at  each  sitting,  and  the  number  of  sittings 
must  be  left  to  the  judgment  of  the  gynecologist. 

Schultze  has  extended  this  method  by  advocating  and  practising,  not 
mere  stretching,  but  actual  separation  of  the  adhesions.  For  this 
purpose  the  patient  is  chloroformed,  the  condition  accurately  mapped 
out,  and  the  adhesions  then  separated  by  bimanual  manipulation. 
Schultze's  results  have  been  good,  but  it  is  evident  that  the  risks  in 
less  experienced  hands  are  very  great. 

In  Prolapsus  uteri  the  method  is  more  complicated  and  troublesome. 
Briefly  it  is  as  follows  (Profanter). 

(1)  Position  of  patient.  The  patient  has  her  dress  thoroughly  loosened 
and  lies  on  a  short  couch  (4  ft.  x  2  ft.  8  in.)  with  her  chest  supported 
by  cushions.  In  this  way  she  is  compelled  to  slacken  the  abdominal 
muscles  as  much  as  possible.  An  assistant  passes  his  fingers  into  the 
vagina,  replaces  and  anteflexes  the  uterus.  The  Masseur  then  with  both 
hands  grasps  the  uterus  and  draws  it  up  as  far  as  possible. 


RELATION  OF  GONORRHOEA  TO  DISEASES  OF  WOMEN.    669 

The  patient  now  raises  the  hips  from  the  couch  thus  supporting  her 
body  on  elbows  and  feet,  while  the  gynecologist  forcibly  separates  her 
closed  knees  and  then  forcibly  approximates  them,  the  patient  resisting 
each  time.  These  manoeuvres  are  repeated  thrice. 

The  object  of  this  so-called  pelvic  gymnastic  is  to  bring  into  action 
the  pelvic  muscles  (levator-ani,  obturator  internus,  perineal  muscles) 
and  thus  strengthen  the  musculature  and  fascia  of  the  pelvic  floor. 

The  patient  need  not  be  confined  to  bed  during  the  intervals  of  the 
treatment. 

RELATION    OF   GONOBRHCEA  TO   DISEASES   OF 

WOMEN. 

LITERATURE.  Eockhart  — Beitrag  zur  Aetiologie  und  Pathologic  des  Harnrohrentrippen 
Sitzungsber  d.  Phyz.  Med.  Gesellsch. :  Wurzburg,  1884.  Bokai — Ueber  das  Con- 
tagium  der  acuten  Blennorrhcea :  All.  Med.  Zeit.,  1880,  No.  74.  Eumm — Der 
Mikroorganismus  der  gonorrhoischen  Schleimhaut  Erkrankungen  :  "Wiesbaden,  1887. 
Cheyne,  W,  W. — Suppuration  and  Septic  Diseases  :  Pentland,  1889.  Metschnikoff— 
Virchow's  Archiv.,  Vol.  107.  Macdonald — Latent  Gonorrhoea  in  the  Female  Sex 
with  special  relation  to  the  Puerperal  State :  Edin.  Med.  Jour.,  June  1873.  Neisser — 
Ueber  eine  der  Gonorrhoe  eigenthiimliche  Micrococcusform  :  Cent,  f iir  die  Med. 
Wissensch.,  1879,  No.  28;  also  Deutsch.  Med.  Woch.,  1882.  Noeggerath—T>i& 
latente  Gonorrhoe  u.  weiblichen  Geschlect.  :  Bonn,  1872.  Oppenheimer — Unter- 
suchungen  iiber  den  Gonococcus  (Neisser) :  Arch,  fur  Gynak.,  Bd.  xxv.,  Hft.  1. 
Sdnger  —  Ueber  die  Beziehungen  der  gonorrhoischen  Infektion  zu  puerperale 
Erkrangungen  :  Verh.  der  Deutsch  Gesell.  fur  Gynakologie,  1886.  Schwarz — Die 
gonorrhoische  Infection  beim  Weibe  :  Volkmann's  Sammlung,  No.  279.  Sinclair — 
Gonorrhoeal  Infection  in  Women :  London,  Lewis,  1888.  Sutton — Introduction  to 
General  Pathology  :  London,  1887. 

"W.  J.  Sinclair's  work  is  the  most  valuable  contribution  to  the  English  literature 
of  this  subject. 

Up  till  1872,  gonorrhoea  in  women  was  not  considered  a  serious 
disease,  and  received  little  special  attention  from  gynecologists. 
Noeggerath's  work,  the  discovery  of  the  importance  of  tubal  disease, 
and,  above  all,  the  recent  progress  in  Bacteriology,  have  alt  tended  to 
show  that  gonorrhoea  is  a  most  important  factor  in  the  causation  of 
gynecological  diseases.  Noeggerath's  clinical  researches  were  specially 
important,  as  he  enunciated  the  doctrine  of  latent  gonorrhoea,  i.e.,  the 
power  of  a  chronic  or  even  insignificant  discharge  in  the  male  urethra, 
when  of  gonorrhoeal  origin,  to  infect  the  female,  and  cause  serious  or 
even  irremediable  disease.  His  work  has  not  only  been  amply  confirmed, 
but  his  theory  of  the  cause  of  gonorrhoea — viz.  the  existence  of  some 
organism — has  now  been  fully  established  by  the  discovery  of  Neisser's 
gonococcus.  Noeggerath  asserted  that  cases  of  obscure  peritonitis  or 
other  inflammatory  affections  in  married  women  were  due  to  an  uncured 
gonorrhoea  of  the  husband,  acquired  even  years  before  marriage,  and 
this  doctrine,  though  disbelieved  by  many  at  the  time,  is  now  in  great 
part  held  by  most. 

A  great  stride  was  made  in  1879  by  the  discovery  of  the  gonococcus 
by  Neisser.  This  investigator  found  that  gonorrhoeal  pus  stained  with 


670  APPENDIX. 

methyl  violet,  and  mounted  in  a  way  to  be  presently  described,  con- 
tained micrococci  quite  characteristic  even  on  microscopical  examination. 
They  are  diplococci  with  concave  surfaces  towards  one  another,  and 
2*2 — 2'5/t  in  length  (p.  147).  Since  Neisser's  discovery  a  very  large 
amount  of  work  has  been  published  on  this  subject,  and  it  has  been  estab- 
lished that  this  gonococcus  is  pathogenic  only  for  gonorrhoea  :  it  has  been 
cultivated,  though  with  difficulty,  in  human  blood  serum,  and  from 
pure  cultivations,  gonorrhoea  has  been  inoculated  in  man  (Bockhart  and 
others).  It  has  been  also  found  (by  Bumm  especially)  to  be  the  cause 
of  gonorrhoeal  ophthalmia  of  infants.  Many  other  interesting  facts 
have  been  ascertained  in  regard  to  it,  e.g.  the  interesting  one  that 
columnar  epithelium  is  its  special  habitat,  not  squamous  epithelium  or 
connective  tissue.  Gonorrhoea  is  thus  cervical,  uterine,  tubal,  urethral : 
not,  strictly  speaking,  vaginal,  peritoneal,  vesical.  It  contrasts  with 
septic  organisms  which  flourish  well  on  squamous  epithelium.  It  is 
alleged  that  some  of  the  sequelae  of  gonorrhoea  can  only  be  accounted 
for  by  a  form  of  mixed  infection,  i.e.  where  a  septic  organism  has  been 
superadded  to  the  gonorrhoeal.  This  has  been  found  to  be  the  case 
in  abscesses  of  Bartholin's  gland  and  in  suppurative  parametritis. 

MetschnikofF s  theory  of  inflammation  applies  well  to  gonorrhoea.  We 
are  to  regard  the  gonococci  as  the  invading  army;  the  tissues,  and  more 
especially  the  leucocytes,  as  the  defenders.  As  the  disease  advances  the 
leucocytes  capture  the  gonococci,  expelling  them  in  pus  cells.  Gradually 
the  leucocytes  conquer  until  the  disease  ends  with  inflammatory 
sequelae  and  few  gonococci.  This  accounts  well  for  all  phases  of  the 
disease  as  well  as  for  the  difficulty  with  which  gonococci  are  found  in 
tubal  mischief  due  to  gonorrhoea. 

Gonorrhoea  is  thus  a  progressive  local  disorder  due  to  the  presence  of  a 
definite  micro-organism  which  may  exist  for  long  in  the  male  urethral 
tissues  (latent),  and  may  infect  a  healthy  mucous  membrane  virulently 
when  its  action  on  its  original  habitat  is  trifling. 

Course  in  the  female.  When  a  woman  is  infected  from  an  acute  or 
subacute  gonorrhoea  of  the  male,  she  has  ordinary  gonorrhoea  as 
usually  described. 

The  prognosis  in  such  a  case  depends  on  the  extent  to  which  it 
spreads,  and  is  serious  when  it  becomes  uterine  or  tubal. 

When  the  gonorrhoea  is  latent  in  the  male  we  then  get  a  case  in 
many  respects  typical.  The  woman  will  usually  give  a  history  of  good 
menstrual  health  prior  to  marriage.  At  a  varying  period  after  marriage 
she  suffers  from  dysmenorrhoea,  menorrhagia  often,  as  well  as  pains  in 
the  iliac  regions.  Sterility  is  commonly  the  rule.  There  may  be  a 
history  of  vesical  discomfort  after  marriage,  but  usually  the  women  do 
not  think  of  infection  as  the  source  of  the  mischief. 

On  local  examination  there  may  be  slight  catarrh  of  the  Bartholinian 


CASE-TAKING.  671 

ducts,  catarrh  of  the  cervix,  pelvic  peritonitis  in  varying  amount  (acute, 
recurrent,  or  chronic)  or  such  an  amount  of  tubal  mischief  as  to  cause 
distinct  lateral  or  posterior  swellings.  For  diagnosis  of  these  several 
conditions  the  student  is  referred  back  to  the  chapters  of  this  Manual 
treating  of  such. 

Prognosis.     Unfavourable. 

Treatment.  It  is  evident  that  gonorrhoea  in  the  male  must  be  scrupu- 
lously treated — that  before  the  patient  is  pronounced  cured  the  discharge 
should  be  examined  for  gonococci,  and  specially  that  the  patient  should 
report  himself  prior  to  marriage  for  further  examination. 

The  same  holds  good  as  to  acute  gonorrhoea  in  the  female.  The 
parts  should  be  carefully  disinfected  with  corrosive  sublimate  (1-2000), 
the  patient  being  chloroformed  if  necessary  in  order  that  the  sublimate 
solution  be  thoroughly  rubbed  in  to  the  vulva  and  vagina.  When  the  gonor- 
rhoea is  cervical,  the  same  may  be  done,  but  there  is  more  risk  of  doing 
harm  and  adding  a  mischievous  septic  organism  to  the  gonorrhoeal  one. 

In  the  form  often  induced  by  latent  gonorrhoea  heroic  treatment  by 
disinfection  is  impossible,  and  therefore  palliative  treatment  is  best, 
as  well  as  great  attention  to  the  general  health.  When  distinct  tubal 
mischief  is  present,  removal  of  the  appendages  is  indicated. 

For  Examination  of  Gonococci  in  Pus. — Clean  two  cover  glasses  and  place  a  drop  of 
pus  on  one.  Put  them  in  apposition  and  then  separate  them  so  as  to  get  a  thin  film  of 
pus  on  each.  Dry  above  spirit  lamp  and  apply  a  drop  of  methyl-violet  stain.  Drain  off 
superfluous  fluid  with  bibulous  paper  and  again  dry  above  lamp.  Wash  in  distilled 
water,  dry,  and  mount  in  Canada  balsam. 

Examine  with  good  microscope,  oil  immersion  lens  and  Abbe's  condenser. 

Gram's  method  does  not  stain  gonococci,  and  thus,  according  to  Roux,  we  have  a 
further  test. 

CASE-TAKING. 

LITERATURE.     Emmet— Gynecology,  p.  57  :  London,  1880.     Simpson,  A.  R. — Contribu- 
tions to  Obstetrics  and  Gynecology,  Method  of  Case-Taking  in  Gynecology,  p.  317. 

It  is  of  importance  to  give  some  hints  as  to  case-taking  or  the  investi- 
gation of  cases  of  diseases  of  the  female  sexual  organs. 

In  hospitals,  some  form  of  case-taking  card  is  usually  employed ;  and 
we  purpose  describing  the  method  of  case-taking  adopted  by  Professor 
Simpson  in  the  Buchanan  Ward  (for  the  Diseases  of  Women)  in  the 
Edinburgh  Royal  Infirmary  (see  page  672). 

We  have  drawn  up  a  schedule1  based  on  this  card  which  will  be  found 
very  convenient,  either  in  private  or  in  dispensary  practice,  for  record- 
ing gynecological  cases. 

Our  first  object  is  to  learn  all  we  can  from  the  patient  herself.  This 
information  is  considered  under  six  heads  and  comprised  under  the 
term  ANAMNESIS,  a  convenient  word,  which  literally  means  a  "  statement 
of  what  she  recollects." 

1  Supplied  by  Messrs  W.  &  A.  K.  Johnston,  Edinburgh,  in  separate  sheets,  or  in  book-form. 


672 


APPENDIX. 


The  questions  asked  under  "  Sexual  History  "  need  little  explanation. 
In  regard  to  Menstruation  as  well  as  abnormal  haemorrhage,  we  may 
note  that  when  either  follows  Amenorrhoea  of  some  weeks'  or  months' 
duration  it  makes  us  suspect  abortion.  Hsemorrhage  coming  on  after 
the  menopause  usually  indicates  cancer,  especially  if  followed  by  foetid 
dischai-ge  (v.  p.  474)  ;  patients  may  complain  of  bleeding  after  coitus 
(p.  474),  which  is  often  an  early  sign  of  carcinoma.  As  to  Dysmenorr- 
hoea  we  should  note  whether  the  pain  is  before,  during,  or  after  the 
flow ;  we  should  also  enquire  as  to  clots  or  shreds  discharged,  and  the 
latter  should  be  examined  microscopically.  For  the  various  conditions 
with  which  Amenorrhoea,  Menorrhagia  and  Dysmenorrhcea  are  associ- 
ated, see  Index  of  Subjects  under  these  heads  and  Chap.  L. 

CASE-TAKING  CARD. 


ANAMNESIS. 

1.  NAME  ;    AGE  ;   OCCUPATION  ;    RESI- 
DENCE ;    MARRIED,    SINGLE,    OR   WIDOW  ; 
DATE  OP  ADMISSION. 

2.  COMPLAINT  AND  DURATION  OF  ILL- 
NESS. 

3.  GENERAL   HISTORY  OF— (a)  Present 
attack ;  (b)  Previous  Health  ;  (c)  Diathesis  ; 
(d)  Social  Condition  and  Habits  ;  (e)  Family 
Health. 

4.  SEXUAL  HISTORY. 

(1)  Menstruation — 

A.  Normal — (a)  Date  of  Commence- 

ment ;  (6)  Type ;  (c)  Duration  ; 
(d)  Quantity  ;  (e)  Date  of  Dis- 
appearance. 

B.  Morbid — (a)     Amenorrhosa  ;      (6) 

Menorrhagia ;  (c)  Dysmenorrhcea. 

(2)  Intel-men strual  Discharge — (a)  Character ; 

(6)  Quantity. 

(3)  Pareunia. 

(4)  Pregnancies — (a)  Number  ;   (6)  Dates  of 

First  and  Last ;  (c)  Abortions  ; 
(d)  Character  of  Labours ;  (e) 
Puerperia  ;  (/)  Lactations. 

5.  LOCAL  FUNCTIONAL  DISTURBANCES — 
(a)  Bladder  ;  (b)  Rectum ;  (c)  Pelvic  Nerves 
and  Muscles. 


6.  GENERAL  FUNCTIONAL  DERANGE- 
MENTS— (a)  Nervous  System ;  (6)  Respiratory 
System  ;  (c)  Circulatory  System  ;  (d)  Diges- 
tive System ;  (e)  Emunctories. 


PHYSICAL  EXAMINATION. 

1.  GENERAL    APPEARANCE   AND    CON- 
FIGURATION. 


2. 

3.  ABDOMEN  —  (a)  Inspection  ;  (b)  Palpa- 
;  tion  ;   (c)  Percussion  :   (d)  Auscultation  ;  (e) 

Mensuration. 

4.  EXTERNAL  PUDENDA. 

5.  PER  VAGINAM—  (a)  Orifice  ;  (6)  Walls 
and  cavity  ;    (c)  Roof  ;    (d)  Os  and  Cervix 
Uteri. 

6.  BIMANUAL  EXAMINATION  (Abdomino- 
vaginal,      Recto-vaginal,     Abdomino-rectal, 
Abdomino-recto-  vaginal,      Abdomino-vesico- 
vaginal)  — 

(1)  Uterus—  (a)  Size  ;   (6)  Shape  ;   (c)  Con- 

sistence ;  (d)  Sensitiveness  ;  (e) 
Position  ;  (/)  Mobility  ;  (g)  Rela- 
tions. 

(2)  Fallopian  Tubes. 

(3)  Ovaries  —  (a)     Size  ;      (6)     Situation  ; 

(c)  Sensitiveness. 

(4)  Peritoneum  and  Cellular  Tissue. 

(5)  Bladder.    (6)  Rectum.    (7)  Pelvic  Bones. 

7.  USE  OF  —  (a)  Speculum  ;  (b)  Volsella  ; 
(c)    Sound  ;    (d)    Curette  ;     (e)   Aspiratory 
Needle  ;  (/)  Tent. 

8.  PHYSICAL  CHANGES  IN  —  (a)  Nervous, 
(b)  Respiratory,  (c)  Circulatory,  (d)  Digestive, 
(e)  Emunctory  Organs  ;  (/)  Skin  ;  (g)  Bones. 

DIAGNOSIS. 

PROGNOSIS. 

TREATMENT. 

PROGRESS  AND  TERMINATION. 


CASE-TAKING. 


673 


Intermenstrual  discharge.  Ascertain  its  colour ;  its  amount — Whether 
it  requires  the  use  of  diapers  ;  and  whether  it  be  foetid,  watery,  or  acrid. 
Leucorrhoea  is  present  in  vaginitis  (p.  528),  cervical  catarrh  (p.  308), 
endometritis  (p.  323),  and  wherever  there  is  secondary  catarrh  of  the 
uterine  mucous  membrane  as  in  retroflexion  (p.  366)  and  uterine  polypi 
(p.  453) ;  it  is  also  present  in  Chlorosis  and  Phthisis.  Foetid  Leucorrhoea 
is  characteristic  of  Carcinoma,  whether  affecting  the  cervix  (p.  474)  or  body 


FIG.  397. 

OUTLINE  DIAGRAM  OF  ABDOMEN  FOR  RECORDING  POSITION  OF  TUMOURS  RELATIVE  TO  THE 
BODY  LANDMARKS. 

of  the  uterus  (p.  502) ;  in  Sarcoma,  it  is  not  foetid  till  the  later  stages 
(p.  508).  For  other  references  to  Leucorrhcea,  see  Index  of  Subjects. 

Pareunia.  This  refers  to  the  absence  or  presence  of  pain  during 
coitus  (v.  p.  531).  It  is  enquired  into  only  in  special  cases,  or  when  the 
patient  complains  of  the  pain.  For  conditions  producing  dyspareunia, 
see  Index  of  Subjects  and  page  531. 

PHYSICAL  EXAMINATION.  The  general  appearance  and  configuration 
should  always  be  noted.  The  sallow  look  of  the  dyspeptic  and  consti- 
pated, yellow  appearance  of  the  chlorotic,  pinched  face  of  the  patient 
2u 


674 


APPENDIX. 


with  ovarian  cyst,  are  in  some  cases  helpful  in  giving  the  hint  as  to  the 
line  of  enquiry.  The  student  should  always  note  anything  in  the  appear- 
ance or  configuration  which  may  enable  him  to  recognise  the  diathesis  of 
the  patient.  It  is  of  importance  to  ascertain  the  occurrence  of  the  gouty 
diathesis  in  a  case  of  dysmenorrhcea,  the  tubercular  diathesis  in  chlorosis, 
and  the  strumous  in  syphilis.  The  physician  will  be  puzzled  by  the 
varied  complaints  of  the  patient  over  some  slight  pelvic  inflammatory 
condition,  unless  he  note  the  thin  and  anxious  face  of  a  patient  of 
nervous  temperament.  Information  gained  in  this  way  is  valuable,  but 
must  be  used  with  discrimination.  Thus  cancerous  patients  are  often 
florid  enough,  while  a  sallow  cachectic-looking  woman  may  have  some 
insignificant  lesion. 


'a, 

FIG.  398. 
OUTLINE  DIAGRAM  OF  PELVIS  FOR  FILLING  IN  POSITION  OF  UTERUS  OR  TUMOURS  (A.  R.  Simpson). 

Mammae.     Note  whether  virginal,  or  those  of  Pregnancy  or  Lactation. 

The  abdomino-vaginal  examination  is  the  ordinary  Birnanual.  The 
abdomino-vesico- vaginal  is  a  rare  form  but  useful  in  some  cases  (p.  600). 
The  tent  is  not  used  as  a  mere  diagnostic  except  in  the  case  of  tumours 
in  the  cavity  of  the  uterus. 

Prognosis.  A  great  deal  depends  on  this.  Thus  we  have  to  tell  the 
patient  whether  her  lesion  is  serious  or  slight,  whether  she  will  get  well 
soon,  or  if  her  trouble  is  chronic  but  not  dangerous.  Unless  she  is  told 
that  it  is  chronic,  she  may  ultimately  come  to  the  conclusion  that  its 
nature  has  been  misunderstood  by  the  physician.  Prognosis  is  often 
difficult  to  give  and  should  always  be  cautious,  especially  as  to  sterility. 

Treatment.  In  no  class  of  cases  has  the  physician  to  be  so  careful  not 
to  do  harm  by  his  treatment.  All  operations  should  be  carefully 


SOURCES  OF  GYNECOLOGICAL  LITERATURE.        675 

considered,  and  only  undertaken  when  \ve  feel  fairly  confident  they  will 
benefit  and  not  make  the  patient  worse.  The  great  success  of  peri- 
toneal operations  is  now  undoubted  ;  but  the  question  as  to  the  actual 
good  resulting  from  repeated  cauterisation  of  the  uterine  mucous  mem- 
brane, division  of  the  cervix,  stitching  of  the  cervix,  etc.,  is  more  sub  lite 
than  is  admitted  in  many  text-books.  The  problem  of  how  to  remove 
cervical  cancer  without  risk  to  life  and  with  a  fair  hope  of  its  non- 


FIG.  399. 

OUTLINE  DIAGRAM  PELVIS  AS  SEEN  THROUGH  THE  BRIM,  TO  FILL  IN  POSITION  OF  TUMOURS 

RELATIVE  TO  UTERUS  (Schultze). 

recurrence  is  at  present  being  worked  out.     Unfortunately  the  patient 
has  frequently  a  return  of  the  disease. 

SOURCES    OF   GYNECOLOGICAL   LITERATURE. 

At  the  beginning  of  each  subject  we  have  already  given  a  summary 
of  the  literature  to  which  we  were  indebted.  The  literature  given,  there- 
fore, represents  what  we  considered  important,  and  what  we  had  in  most 
cases  personally  studied. 

Gynecological  Literature  is  so  extensive  that  a  full  resume  of  it  would 
have  occupied  several  times  the  space  we  have  allotted  to  the  whole 
subject.  We  wish  however  to  point  out  here  the  sources,  so  that  any 
practitioner  who  wishes  to  ascertain  the  best  books  and  monographs  on 
any  special  subject  may  know  how  and  Avhere  to  begin  his  search. 

The  sources  of  Gynecological  Literature  are  threefold  : — 

I.  Catalogues,  Dictionaries; 
II.   The  larger  Text-books  of  Gynecology  ; 

III.  Articles  and  Abstracts  in  the  various  Gynecological  quarterlies, 
monthlies,  and  weeklies,  with  Retrospects  and  Jahrbucher. 


676  APPENDIX. 


I.  CATALOGUES,  DICTIONABIES. 

(1.)  Index-  Catalogue    of    the   Library    of    the    Surgeon-  General's    Office,    U.S.A. 

Washington    Government    Printing    Office.      In    this    splendid    work,    the 

authors  and  works  are  arranged  alphabetically  ;   its  value  cannot  be  over- 

rated. 

(2.)  Nouveau  Dictionnaire  de  Medecine  et  de   Ohirurgie  pratique:  Paris,   J.    B. 

Baillie're  et  Fils. 

Dictionnaire  Encyclopedique  des  Sciences  Medicales:  Asselin  et  Cie,  Paris. 
Real-Encyclopddic  der  gesammten  Heilkunde  :  Wien. 
Wood's  Cyclopcedia. 

Annual  of  the  Universal  Medical  Sciences  (edited  by  Sajous)  :  Philadelphia. 
Buck's  Reference  Handbook  of  the  Medical  Sciences  :  New  York. 


(3.) 
(4.) 


II.  LARGER  MODERN  TEXT-BOOKS  OP  GYNECOLOGY. 

ENGLISH. 

Barnes  —  Diseases  of  Women  :  London,  J.  &  A.  Churchill. 

Byford  —  Medical  and  Surgical  Treatment  of  Women  :  Philadelphia. 

Duncan,  Matthews  —  Diseases  of  Women  :  London,  Churchill. 

Edis  —  Diseases  of  Women  :  London,  Smith,  Elder,  &  Co. 

Emmet  —  Principles  and  Practice  of  Gynecology  :  Philadelphia,  Lea's  Son  &  Co. 

Goodell  —  Lessons  in  Gynecology  :  Philadelphia,  Brinton. 

Hewitt  —  The  Diseases  of  Women  :  London,  Longmans,  Green  &  Co. 

Mundt  —  Minor  Surgical  Gynecology  :  New  York,  Wood  &  Co. 

Simpson,  A.  R.  —  Obstetrics  and  Gynecology  :  Edinburgh,  A.  &  C.  Black. 

Simpson,  Sir  J.    Y.  —  Diseases  of  Women  :   (edited  by  A.   R.  Simpson)  :  A.  &  C. 

Black. 

Sims,  J.  Marion  —  Uterine  Surgery  :  London,  Hardwicke. 
Skene,  A.  J.  C.  —  The  Diseases  of  Women,  Treatise  on  :  London,  Lewis. 
Ta.it,  Lawson  —  Diseases  of  Women  :  W.  Wood  &  Co.,  New  York. 

The   Pathology  and  Treatment    of   Diseases  of   the  Ovary  :   Bir- 
mingham. 

Diseases  of  Women  and  Abdominal  Surgery,  Vol.   I.  :   Leicester, 

Richardson  &  Co. 

Thomas  —  Treatise  on  Diseases  of  Women  :  London,  Kimpton. 
Thorburn  —  Diseases  of  Women  :  Griffin,  &  Co.,  London. 
Wells,  Sir  T.  S.  —  Ovarian  and  Uterine  Tumours  :  London. 
West  (Duncan's  Edition)  —  Diseases  of  Women  :  Churchill. 

GERMAN. 

Fritsch  —  Krankheiten  der  Frauen  :  Braunschweig. 

Hegar  und  Kaltcnhach  —  Die  operative  Gynakologie,  3te,  Aufl  :  Stuttgart,  Enke. 

Hofmeier  —  Grundriss  der  Gynakologischen  Operationen  :  Leipzig. 

Schroeder  —  Handbuch  der  Krankheiten  der  weiblichen  Geschlechtsorgane  :  Leipzig, 

Vogel. 
Winckel  —  Lehrbuch  der  Frauenkraukheiten  :  Hirzel,  Leipzig. 

Handbuch  der  Frauenkrankheiten  redigirt  von  Billroth  u.  Luecke  : 

Enke,  Stuttgart. 
I.  Band.  Die  Untersuchung  der  weiblichen  Genitalien  und  allgemeine  gyniikolo- 

gische  Therapie  —  Chrobak. 

Die  Sterilat  der  Ehe.  Entwickelungsfehler  des  Uterus  —  Midler. 
Die  Lageveranderungen  und  Entziindungen  des  Uterus  —  Fritsch. 
II.  Band.  Die  Neubildungen  des  Uterus  —  Gusseroio. 
Die  Krankheiten  der  Ovarien  —  Olshausen. 

Die  Krankheiten  der  Tuben,  der  Ligamente,  des  Becken-peritonilum  und 
des  Beckenbindegewebes,  einschliesslich  der  Extrauterinschwanger- 
schaft  —  Bandl. 
III.  Band.  Die  Krankheiten  der  weiblichen  Brustdriisen  —  Billroth. 

Die  Krankheiten  der  ausseren  Genitalien  und  die  Dammrisse—  Zweifd. 
Die  Krankheiten  der  weiblichen  Harnrohre  und  Blase  —  Winckel. 
Die  Krankheiten  der  Vagina  —  Breisky. 


SOURCES  OF  GYNECOLOGICAL  LITERATURE.        677 


FRENCH. 

Bernutz  and  Goupil — Clinical  Memoirs  on  the  Diseases  of  Women :  Sydenham 

Society  Tr. 
Courty — Traite  pratique  des  Maladies  de  1'uterus,  2nd  Edition  :    Paris,   Asselin : 

also  Dr.  Agnes  Maclaren's  Translation,  London. 
De  Sinety — Manuel  Pratique  de  Gynecologic  :  Paris,  Doin. 
Leblond — Traite  elementaire  de  Chirurgie  gynecologique  :  Paris. 
2Vtpwr— Legona  cliniques  sur  les  Maladies  des  Femmes  :  Paris,  Doin. 

III.  JOURNALS  :  RETROSPECTS  :  INDEXES  :  JAHRBUCHER. 

American  Journal  of  Obstetrics  :  New  York,  "Wm.  "Wood  &  Co. 

British  Medical  Journal :  London. 

Cassell's  Year  Book  of  Treatment. 

Dublin  Journal  of  Medical  Science  :  Dublin,  Fannin  &  Co. 

Edinburgh  Medical  Journal :  Edinburgh,  Oliver  &  Boyd. 

Glasgow  Medical  Journal  :  Glasgow,  MacDougal. 

International  Journal  of  Medical  Sciences  :  Lea's  Son  &  Co.,  Philadelphia;  Cassell 

&  Co.,  London. 
Lancet :  London. 

London  Medical  Record  :  Smith,  Elder  &  Co. 
Medical  Press  and  Circular  :  London. 
New  York  Medical  Journal  and  Obstetrical  Review  :  New  York,  Appleton  &  Co. ; 

and  London,  Cassell  &  Co. 

Reference  Handbook  of  Medical  Sciences  :  Wood  &  Co.,  New  York. 
Archiv  fur  Gynakologie  :  Berlin,  Hirschwald. 
Berliner  klinische  Wochenschrift. 

Centralblatt  fiir  Gynakologie  :  Leipzig,  Breitkopf  und  Hartel. 
Zeitschrift  fur  Geburtshtilfe  und  Gynakologie  :  Stuttgart,  Enke. 
Archives  de  Tocologie  et  des  Maladies  des  Femmes,  etc. :   Paris,  Delahaye  et  E. 

Lecrosnier. 

Annales  de  Gynecologic,  Paris. 

Annali  di  Ostetricia,  Ginecologia  e  Pediatria  :  Milano,  Pietro  Agnelli. 
Braithewaite's  Retrospect :  London,  Simpkin,  Marshall  &  Co. 
Index  Medicus :   a  monthly  classified  Record  of  the  current  Medical  Literature  of 

the  World  :  G.  S.  Davis,  Boston  and  Detroit,  U.S.A. 

Annual  of  the  Universal  Medical  Sciences  (Edited  by  Sajous) :  Davis,  Philadelphia. 
Schmidts's  Jahrbiicher :  Leipzig. 
Supplement  to  Ziemssen's  Cyclopaedia :   London,  Sampson  Low,  Marston,  Searle, 

&  Rivington. 

Revue  des  Sciences  Medicales  :  Paris,  E.  Masson. 
Neale's  Digest :  London,  Ledger,  Smith  &  Co.,  1882. 

American  Gynecological  Transactions  (Index  at  end) :  Boston,  Houghton  &  Co. 
London  Obstetrical  Transactions  :  Longmans,  Green  &  Co. 
Edinburgh  Obstetrical  Transactions  :  Oliver  &  Boyd. 

In  looking  up  literature  on  any  special  subject,  first  consult  the  litera- 
ture given  at  the  beginning  of  each  chapter  and  then  the  index  of  Recent 
Gynecological  Literature  in  the  Appendix.  The  list  of  literature  given 
in  Billroth  and  Luecke's  Handbuch,  the  Index  Medicus,  Neale's  Digest 
and  the  U.  S.  A.  Index  Catalogue  may  also  be  consulted  with  advantage. 
The  various  Retrospects  and  Jahrbiicher  mentioned  above  give  abstracts 
of  the  papers,  and  the  French  and  German  Cyclopaedias  give  special 
exhaustive  articles  on  each  subject. 


X 


OP 


INDEX 

OF 

RECENT    GYNECOLOGICAL   LITERATURE. 

The  following  index  aims  at  giving  reference  to  all  the  important  contri- 
butions to  Gynecological  Literature  in  the  leading  journals  from  January 
1886,1  the  year  in  which  the  last  edition  of  this  Manual  was  published, 
to  the  end  of  1888.  The  purpose  is  not  to  enable  the  reader  to  lay  his 
hand  on  the  papers  of  particular  authorities  (as  this  has  already  been 
done  in  the  ordinary  index  of  each  Journal),  but  to  gather  together  for 
him,  from  the  best  and  most  accessible  Journals,  all  the  material  con- 
nected with  the  subject  he  may  be  reading  up.  The  journals  indexed 
are  the  following  : — 

British  Medical  Journal,  contraction  Brit.  Med.  Jour. ; 

Lancet,  Lancet ; 


Edinburgh  Medical  Journal, 

Glasgow  Medical  Journal, 

Dublin  Journjil  of  Medical  Science, 

American  Journal  of  Obstetrics, 

Archiv  ftir  Gynakologie, 

Centralblatt  ftir  Gynakologie, 

Zeitschrift  fiir  Geburtshiilfe  und  Gynakologie, 

Volkmann's  Sammlung, 

Archives  de  Tocologie, 

Annales  de  Gynecologic, 

Annali  di  Ostetricia, 


Edin.  Med.  Jour.; 
Glas.  Med.  Jour.; 
Dub.  Med.  Jour.; 
Amer.  Jour.  Obstet.; 
Archiv  f.  Gyn. ; 
Centralb.  f.  Gyn.; 
Zeitsch.  f.  Geb.  und  Gyn.; 
Volk.  Samml.; 
Archiv.  de  Toe.; 
Annal.  de  Gyn.; 
Annal.  di  Ostet. 


The  topics  have  to  a  certain  extent  been  classified  and  grouped  alpha- 
betically. Under  each  topic  the  papers  are  arranged  in  order  as  they 
appear  in  each  volume  of  the  journal ;  this  will  enable  the  reader,  as  he 
happens  to  have  access  to  the  volumes  of  a  journal,  to  refer  to  all  the 
papers  in  it  which  bear  on  that  topic.  The  catch-word  indicates  the 
drift  of  the  paper,  which  in  getting  up  the  literature  of  a  subject  is 
more  useful  than  the  writer's  name ;  in  operations,  however,  the  name 
of  the  operator  is  given. 

Our  aim  has  been  to  make  an  index  which  will  give  references  to 
sources  within  the  reach  of  the  majority  of  practitioners.  Transac- 
tions of  Societies,  containing  papers  in  full,  are  not  to  be  found  in 

1  The  literature  of  the  preceding  three  years  will  be  found  in  the  Third  Edition. 


682  APPENDIX. 

all  libraries ;  hence  we  have  preferred  to  give  the  reference  to  Journals 
which  may  perhaps  only  refer  to  the  paper,  and  the  reader  desiring 
further  information  must  go  to  the  Transactions  themselves.  Reference 
to  the  Proceedings  of  the  Societies  and  Associations  will  be  found  in 
the  Journals  as  follows :  London  Obstetrical  Society,  British  Gyneco- 
logical Society,  and  many  papers  in  other  English  Societies,  Brit.  Med. 
Jour,  or  Lancet ;  Edinburgh  Obstetrical  Society,  Edin.  Med.  Jour. ; 
Obstetrical  Section  of  British  Medical  Association,  Brit.  Med.  Jour.  ; 
Obstetrical  Section  of  Academy  of  Medicine  of  Ireland,  Dub.  Med.  Jour.  ; 
New  York  and  Philadelphia  Obstetrical  Societies  and  American  Gyne- 
cological Association,  Amer.  Jour.  Obstet.  ;  Societe  Obstetricale  et  Gyne- 
cologique  de  Paris.  Societe  de  Chirurgie,  Academic  des  Sciences,  Societe 
medicale  des  Hdpitaux,  in  Archiv.  de  Toe.  or  Annal.  de  Gyn. ;  Gesell- 
schaft  fur  Geburtshiilfe  und  Gynakologie  zu  Berlin,  and  Gynecological 
Section  of  the  Versammlung  deutscher  Naturforscher  und  Aertzte,  in 
Zeit.  f.  Geb.  u.  Gyn.,  Archiv  f.  Gyn.,  or  Centralb.  f.  Gyn. 


INDEX    OF    RECENT   GYNECOLOGICAL 
LITERATURE. 


})ol: 
I  Ml 


ABDOMINAL  SURGERY. 

BRIT.  MEU.  JOUR.  1886,  I.  193,  For  small 
pelvic  tumours  by  Cullingvvorth  ;  350,  Removal 
of  large  fatty  tumourof  omentum  by  Meredith ; 
410,  Ideal  cholecystotomy ;  930,  1042,  Peri- 
toneal surgery;  1063,  110!',  11(37,  Cases  by 
Mayo  Robson  ;  11  Oil,  Laparotomy  for  cystic 
myoma,  Walter ;  1170,  Laparotomy  for  hydatid 
tumours.  1886,  II.  433,  Extirpation  of  \ 

Cyst  of  omphalo-mesenteric  duct  by  Schoad  ; 
852,  General  principles  in  removal  of  uterine 
appendages.  1887,  I.  170,  Puncture  with 

aspirating  needle  ;  355,  417,  480,  541,  592,  647, 
697,  Skene  Keith's  statistics  of  ;  480,  Ascites 
after    laparotomy ;    568,   Exploratory   lapar- 
otomy  ;  593,  698,  752,  Ventrotomy  as  term  for 
'  Abdominal  Section  ; '  776,  Sequel  to  gastro- 
enterostomy ;    975,   1031,  Abdominal  section  ! 
by    Sir   W.   MacCormac  for    intra-peritoneal 
injury  ;   1000,  Treatment  of  intra-peritoneal  | 
injury  ;      1178,     Laparotomy     in     America. 

1887,  II.  17,  For  venal  hydatids  by  Imlach ; 
727,    Puncture    of    the  heart  in   chloroform  '• 

oisoning  ;     829,     Abdominal     section     by 
Lamniiman  for  stoppage  of  the  bowels  ;  1061,  i 
Laparotomy  for  peritonitis ;  1442,  Laparotomy  ' 
in  puerperal  fever.  1888,  I.  128,  Three  t 

unusual  cases  of  abdominal  section  by  Stuart 
Nairne;  136,  Laparotomy  by  Chitton  for 
obstruction  from  gall-stone ;  711,  Menstrual 
bleeding  from  a  laparotomy  scar  ;  932,  Lapar- 
otomy by  Von  Dutel,  for  acute  cystitis ;  971, 
Section  by  Garrigues  for  ruptured  uterus. 

1888,  II.   172,  Some  aspects  of;   938,  Some 
points  affecting  the  mortality  of  abdominal 
section  ;    1050,    Laparotomy  by    Keetley  for 
suppurative  peritonitis  ;   1096,  Lawson  Tail's 
conclusions    from    a    second    series    of    one 
thousand  sections  ;    1336,  Abdominal  section 
by  M'Mordie  for  large  fibroid ;  1403,  Flushing 
the  peritoneum. 

LANCET.  1886,  I.  343,  Note  on  abdominal 

sections ;  1222,  Abdominal  section  by  Wade, 
for  ovarian  and  fibroid  tumour  at  same  time.  '. 

1886,  II.  669,  Two  cases  of  abdominal  section 
by  Underbill  ;  774,  Three  cases  of  section  by 
Imlach.        1887,  I.  310,  Section,  by  Mackay, 
for  pelvic  suppuration  ;  518,  568,  An  hundred 
consecutive  sections,  by  Granville  Bantock  ; 
503,  Inaugural  address  to  Obstet.  Soc.  London  ; 
586,  Section,  statistics  of  at  Kieff ;  622,  Section 
by  Elder,  for  pyosalpinx  and  sub-peritoneal 
myoma ;   1134,  Cases  of  section  by  Truman. 

1887,  II.  205,  257,  Sixty-four  cases  of  section 
by  Cullingworth  ;  800,  Condition  and  manage- 
ment of  the  intestine  after  section  ;    1008, 
Seven    consecutive    laparotomies,    by    Balls- 
Headley  ;    1111,     Supra-pubic     incision    by 
Gibbons  and  Parker,  for  removal  of  tumour 
from  female  bladder ;  1203,  Purgation  (hiring 
convalescence    after    section.       1888,  I.    268, 
Two    cases  of    laparotomy   by  Homans,   for 
tubercular  peritonitis  ;  470,  Review  of  three 
hundred    and     eighty-four     laparotomies   by 
Homans  ;     681,     Section    for    extra-uterine 


gestation,  by  Rutherford  Morison  ;  719, 
Section  for  peritonitis,  by  Smith  and  Burford  ; 
919,  Ctesarean  section  for  impacted  fibroid ; 
1132,  Five  cases  of  Section  by  O'Callaghan. 
1888,  II.  675,  Section  by  Lawson  Tait,  for 
congenital  cyst  of  urachus  ;  803,  855,  Second 
series  of  sections  by  Cullingworth  ;  817, 
Mortality  of  Abdominal  Section  ;  904,  Cases, 
by  Neve;  1002,  Section  by  Bull,  for  hydatid 
cyst  of  the  liver  ;  1005,  By  Pepper,  for  double 
tubercular  pyosalpinx  and  strangulated 
femoral  hernia  ;  1170,  Two  coses  of  section  by 
Mayo  Robson  for  tubercular  peritonitis. 
EDIN.  MED.  JOUR.  XXXI.,  II.  1066,  1142, 

Lawson  Tait  on  Abdominal  Section  ;  1176, 
Treatment  of  fibrornyomata  by  laparotomy. 
XXXII.,  I.  212,  Successful  laparotomy  by 
Wallace ;  466,  On  the  so-called  laparotomy 
epidemic.  XXXII.,  II.  673,  736,  Series  of 

sections  by  Halliday  Groom  ;  954,  Intestinal 
obstruction  after  abdominal  operations. 
XXXIII. ,  II.  1001,  Deep-buried  continuous 
animal  suture  in  laparotomy.  XXXIV.,  I. 
40,  140,  Notes  of  a  year's  work  in,  Rutherford 
Morison;  117,  171,  Twelve  laparotomies  by 

GLAS.  MED.  JOUR.  XXVIII.  101,  Thirty 

cases  of  section,  by  Cameron. 

DUB.  MED.  JOUR.  LXXXI.  500,  Laparotomy 
for  intestinal  obstruction.  LXXXII. 

1,  115,  So-called  laparotomy  epidemic. 
LXXXVI.  75,  Notes  of  five  cases  of  section  by 
O'Callaghan ;  456,  An  abdominal  salpingotomy 
in  the  last  century. 

AMER.  JOUR.  OBST.  1886.  44,  Section  by 

Kelly  for  removal  of  cervical  fibroids ;  59, 
Acute  pulmonary  radema  following  lapar- 
otomy ;  62,  Inclusion  of  a  piece  of  omentum 
in  a  glass  drainage-tube  ;  65,  Extra-peritoneal 
incision  for  small  pelvic  abscess,  by  Polk  ;  88, 
In  England,  Scotland,  and  Heidelberg  ;  113, 
Treatment  of  pelvic  abscess  by  incision  and 
drainage ;  272,  Ventral  hernia  following  lapar- 
otomy ;  414,  A  year's  work  in  laparotomy, 
Goodell ;  408,  Laparotomy  for  myoma ;  468, 
Ibid.  ;  469,  Ibid.  For  pyosalpinx  ;  471,  Explor- 
atory incision  ;  491,  Exploratory  puncture  and 
excision ;  551,  Four  cases  with  remarks  by 
Eastman ;  611,  Indications  for  drainage  after 
laparotomy ;  013,  Laparotomy  for  double 
cystomaovariipapillare,  Lee ;  645,  Laparotomy 
for  pelvic  abscess ;  663,  Statistics  of  abdominal 
section ;  671,  Laparotomy  for  traumatic 
rupture  of  the  gravid  uterus ;  825,  Statistics  of 
abdominal  section ;  869,  After-treatment  of 
lai>arotomy  ;  897,  Glimpse  of  laparotomy  in 
Europe  ;  971,  Section  for  pelvic  abscess  ;  992, 
lodoform  in  severe  laparotomy;  1169,  Lapar- 
otomy for  tu bo-ovarian  abscess,  by  Kelly ;  1136, 
Thirty-three  laparotomies  by  Helmuth  ;  1259, 
Laparotomy  for  intestinal  obstruction,  Wylie  ; 
1201,  Ibid,  for  doubtful  ovarian  cyst,  Hunter; 
1271,  Laparotomy  followed  by  multiple  neuro- 
mata of  abdominal  wall ;  1296,  Laparotomy 
for  extra-uterine  pregnancy,  by  Muratow ; 


684 


APPENDIX. 


1297,  Intestinal  disturbance  after  abdominal 
operation.    1887,25,  52,  Ventral  Hernia  caused  ; 
by    Ijjtparotomy ;    [>4,  Irrigation    in  collapse 
during  laparotomy ;  58,  Laparotoniy  for  pyp- 
salpinx  with  abscess  of  one  ovary,   Mmide  ; 
180,  Thirty-one  cases,  Price  ;  449,  Laparotomy  ' 
for  solid  uterine  and  ovarian  tumours,  Mann  ;  j 
669,  A  laparo-salpingotomy  in  1784  ;  721,  Two  ' 
laparotoniies   with    same   patient,    Kin  loch  ;  I 
74'.i,    Sections,    by   Price;    753,    Section    for 
intestinal  perforation,  Haynes  ;  932,    Lapar-  i 
otomy  for  tuberculosis  of  peritoneum,  Van  de  j 
Warker ;    1048,   Drainage   after  laparotomy  ;  , 
1058,  Death  from  rare  cause  after  laparotomy  ;  j 
1000,  Operation  for  ventral  hernia  after  lapar- 
otomy ;  1154,  Primary  laparotomy  for  extra-  j 
uterine ;  1183,   Acute  dilatation  of  stomach  j 
after    laparotomy ;    12C9,    Peculiar   cases   of 
section  ;     127!',    Laparotoniy    for    tube     and  i 
ovarian  cyst,  Nilsen.        1888. 15,136,  A  year's  j 
work    in    laparotomy,    Munde ;    99,    During 
tuberculosis   of   peritoneum,    Fehling ;    15(5,  i 
Laparotoniy  for  large  fibroid,   by   Romans  ;  ' 
321,  Exploratory  incision,  Montgomery  ;  408, 
Laparotomy  for  septic  peritonitis,  Boldt ;  410,  \ 
Laparotomy  for  hystero-epilepsy,  Lee ;  513,  i 
Laparotomy       for      removal     of       uterine 
appendages,  death  from  ether ;  734,   Lapar-  , 
oiomy  during  1887,  Goodell ;  874,   A  year's 
work  in,  Dudley  ;  916,  Ibid.,  Eastman  ;  »31, 
Five  successive  laparotomies ;  945,  Hysterec- 
tomy, ovariotomy,  and  abdominal  section  on 
one  subject,  Baldy ;  1006,  Injury  to  bladder  , 
dviring  laparotomy,  Sanger ;  1069,  Indications 
for  drainage  in  ;  1076,  Laparotomy    in  peri- 
tonitis ;  1078,  Relation  of  abdominal  surgeon 
to  the  obstetrician  and  gynecologist ;    1116, 
Intestinal  occlusion  after  laparotomies  ;  1183, 
Exploratory     laparotomy,     carcinoma     and 
fibroid,  Nilsen  ;  1209,  Laparotomy  for  removal 
of  uterine  appendages,   Hall ;   1302,    Twelve 
months  of  abdominal   and  vaginal  section, 
Byford  ;  1303,  Abdominal  Surgery,  Price. 
ARCH1V  F.  GYN.  XXXI.  464,  Laparotomy 

for  tuberculosis  of  peritoneum.  XXXII. 

465,  Injury  to  bladder  during  laparotomy, 
Sanger ;  507,  Constriction  of  gut  after  lapar- 
otomy. 

CENTKALB.  F.  GYN.  X.  27,  Laparotomies  by 
Schrainm ;  41,  Laparotomy  for  tubercular 
peritonitis,  Naumaun ;  110,  Laparotomy  for 
hernia,  Wiesmann ;  214,  Parotitis  after 
laparotomy  ;  227,  Sublimate  in  laparotomy  ; 
497,  Laparotomy,  Nagel ;  649,  Laparotomy  for 
myoma,  Hager ;  745,  Laparotomy  for  inversion, 
Schmalfuss.  XI.  201,  Laparotomy  in 

Russia,  1784;  594,  Laparotomies,  Schultze ;  753, 
Peritonitis  after  laparotomy ;  790,  Laparotomy 
for  haematometra  and  haematosalpinx, 
Trzebicky ;  822,  Laparotomy  in  tubercular 
peritonitis,  Schmalfuss.  XII.  10,  91,  Death 
after  laparotomy  ;  217,  Laparotomy  on  second 
day  of  puerperium,  Sippel ;  319,  Laparotomy 
in  pregnancy ;  406,  Repeated  laparotomy, 
Martin  ;  456,  Ibid.  ;  690,  Iversen  on. 
VOLK.  S AMM  L.  No.  339,  Sixty  cases  of  laparo- 

myotomy,  Fritsch. 
ARCH1V.     DE    TOO.  1887.    577,     Laparo- 

elytrotomy,  Clarke. 

ANNAL.  DE  GYN.  XXIX.  255,  Drainage  and 
antiseptic  packing  of  peritoneum.  XXX. 

108,  Laparotomy  for  salpingitis  and  ovaritis, 
Terrillon. 

ANNAL.  DI  OSTET.  1888. 164,  Elastic  ligature 
for  intra-peritpneal  treatment  of  pedicle  ;  215, 
Cases  of  Section,  Sani  ;  370,  Seven  cages  of 
Section,  Fasola. 

ABDOMINAL  TUMOURS  (and  unclcused  Pelvic 

Tuntnurg). 
BRIT.  MED.  JOUR.  1886,  II.,  978,  Twelve 

Cases  of  extra-peritoneal  cysts.  1887,  I. 


132,  The  heart  and  large  abdominal  tumours  ; 
782,  Mucous  polypus.  1888,  II.  1222, 

Fibroid  tumours  undergoing  calcareous  degen- 
eration. 

LANCET.  1887,  II.  213,  Successful  removal 

of  abdominal  cyst  of  large  size,  by  Robson. 
1888,  I.  1015,  1067,  On  cardiac  degeneration 
produced  by  pressure  of. 

EDIN.  MED.  JOUR.  XXXI,  II.  881,  Removal 
of  tumours  of  abdominal  wall  with  their 
peritoneum,  by  Sanger. 

AMER.  JOUR.  OBd.  1886.  1216,  Non-ovarian 
dermoid  ;  1271,  Multiple  neuromata  of 
abdominal  wall  following  laparotomy. 

1887,  65,  Sarcoma.  1888,  1093,  Desmoid 
of     abdominal    wall  ;      1102,     Fibroids     of 
abdominal  wall  ;   1110,  Opening  of  cystic  l>y 
two  operations,  Keil. 

CENTRALB.  F.  GYN.  X.  78,  Exploratory 

incision  in,  Terillon  ;  115,  Echinococcus  ;  120, 
Ischuria  after  extirpation  of  ;  281,  Echino- 
coccus ;  299,  Deep  abdominal  wall  abscess ; 
710,  Echinococcus.  XII.  790,  Cases, 

Minkowski. 

ZEITSCH.  F.  GEB.  UND  GYN.  XIV.  413, 

Of  wall. 

ARCHIV.  DE  TOG.  1887.  473,  517,  Phleg- 

monous  tumour  close  to  uterus  ;  857,  Multiple 
hydatid  cyst. 

ANNAL.  DE  GYN.  XXV.  US,  Accidents  to 

intestine  in.  XXVI.  18,  Sub-peritoneal 

myoma  in  pregnancy,  with  peritonitis. 

ANNAL.  DI  OSTET.        1887.  148,  Echinococcus. 

1888.  1,  Echinococcus  of  spleen. 

AMENORRHCEA. 

BRIT.  MED.  JOUR.        1886,  II.  1114,  Binoxide 

of  Manganese  in.         1887,  I.  926,  Treatment. 

1888,   I.    1383,   Associated   with   Alcoholism. 

1888,  II.  876,  From  imperforate  hymen. 
LANCET.  1886,  I.    61,    Santonin  in  ;    132, 

Ibid.  ;    286,    Ibid.  ;    789,    Treatment ;    1133, 

Permanganate  of  Potash  in. 

EDIN.  MED.  JOUR.        XXXI.,  II.  1176,  Santo- 
nine  in. 
DUB.  MED.  JOUR.  LXXXI.  34,  Oxalic  acid 

as  an  emmenagogne.  LXXXII.  436,  Note 

on.        LXXXV.  85,  Potassium  permanganate. 
AMER.  JOUR.  OBS.          1886.  496,  Endometritis 

fungosa  with  amenorrhoea.  1887.  1112, 

Intra-uterine     stem     as    an    emmenagogue. 

1888.    445,     In     connection    with    diabetes 

inellitus  and  insipidus. 

CENTRALB.  F.  GYN.        X.  32,  Manganese  in. 
ZEITSCH.  F.  GEB.  UND  GYN.         XIV.  194,  In 

diabetes. 
ARCHIV.  DE  TOO.  1886.  539,  Oxalic  acid  as 

an  emmenagogue. 

ANAESTHESIA. 

BRIT.  MEU.  JOUR.  1887, 1.  451,  674,  888, 

Drumine  ;  800,  Menthol ;  819,  "Analgesics;" 
876,  Effects  of  cocaine;  927,  Cocaine;  1126, 
Methylol  ;  1229,  Cocaine  habit  and  addiction, 
1400,  Subcutaneous  infection  of  cocaine. 
1887,  II.  68,  132,  Dmmine  ;  216,  Cocaine  in 
operation  for  anal  fistula ;  507,  Insanity 
following  anaesthetics ;  727,  Puncture  of  the 
heart  in  chloroform  poisoning  ;  729,  Steno- 
carpine  ;  894,  Methylol;  1021,  Deaths  from 
chloroform  ;  1181,  Carbonic  acid  ;  1199, 
Insanity  following.  1888,  I.  19,  Pleasant 

anaesthetic  mixture ;  87,  Amylene  hydrate 
or  tertiary  amyl  alcohol  ;  100,  Cocaine 
poisoning ;  279,  Drumine ;  317,  The  Haya 
poison ;  323,  And  respiration  ;  349,  Alarming 
symptoms  from  spraying  throat  with  cocaine  ; 
438,  Cocaine  poisoning ;  490,  Local  ;  545, 
Erythrophhein  ;  549,  Amylene  hydrate  ;  604, 
Haya  poison  and  Erythrophloaum  ;  709, 
Cocaine  and  its  salts  ;  757,  Cocaine  poisoning  ; 
864,  Sulphonal ;  918,  Boldin  ;  933,  Menthol ; 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    685 


902,  Hypnotism  ;  1171,  1248,  Etherisation  : 
an  unrecognised  danger  ;  1184,  Canadol ;  1211, 
Methylene  and  other  local  anaesthetics  ;  1213, 
1308,  Codeine  to  relieve  pain  in  abdominal 
disease  ;  1301,  Methylene  ;  1382,  Use  of 
codeine.  1888,  II.  203,  Methlyene  ;  243, 

Chloride  of  Methyl  ;  243,  Helleborin  ;  274, 
Methylin  ;  450,  Local ;  454,  Methylene  ;  1071, 
Death  from  chloroform  ;  1124,  Antipyrin  ; 
1239,  "  Nerves  "  and. 

LANCET.  1886,  II.  411,  Cocaine.  1887,  I. 
105,  Extractum  kavadepuratum ;  587,  Cocaine ; 
780,  Ibid.,  dangers  of  ;  1089,  Selection  and 
administration  ;  1297,  Death  from  chloroform 
and  fear.  1887,  II.  519,  Cocaine  ;  616,  Notes 
on  anaesthetics  ;  616,  Guide  to  administration ; 
858,  Cocaine  ;  1265,  Poisoning  by  cocaine  sub- 
cutaneously.  1888,  I.  14,  Experience  of 

cocaine  ;  119,  Cocaine  in  reflex  vomiting  ;  190, 
Erythrophkein  ;  380,  Cocaine  in  urethral 
operations ;  394,  Cocaine  poisoning ;  590, 
Cocaine  and  its  salts  ;  871,  Novel  extension  of 
uses  of  cocaine ;  572,  Toxic  effects  of  cocaine 
subcutaneously  injected  ;  1013,  In  grave 
constitutional  disorders  ;  1024,  Antipyrin  as 
an  anodyne  ;  1041,  Acute  and  chronic  cocaine 
poisoning.  1888,  II.  Combined  chloroform 
and  Cocaine ;  523,  Use  of  Anaesthetics ;  689, 
839,  The  teaching  of  ;  715,  Toxic  effects  of 
Cocaine  ;  863,  Dosage  of  chloroform  ;  888,  Use 
of  ;  1144,  Chloroform  as  a  routine  anaesthetic ; 
1220,  Introduction  of  ether  inhalation  into 
London. 

EDIN.      MED.     JOUR.  XXXIV.,  I.     477, 

Helleboreine. 

GLAS.  MED.  JOUR.  XXVIII.  262,  Use  of  the 
more  common  anaesthetics.  XXIX.  173, 

Ether  or  Chloroform — which? 

DUB.  MED.  JOUR.  LXXXI.  247,  Hypnone  ; 

2S5,  Urethran.  LXXXIL  95,  Urethran  ; 

525,  The  cocaine  habit.  LXXXIII.  150, 
Poisoning  by  cocaine ;  313,  On  cocaine  ;  406, 
Test  for  cocaine  ;  456,  Coca,  cocaine  and  its 
salts. 

AMER.  JOUR.  OBS.  1886.  100,  Nitrous  oxide 
with  oxygen  ;  1118,  Cocaine  in  plastic  surgery  ; 
1264,  Cocaine.  1888.  513,  Death  from  ether 
during  laparotomy  for  removal  of  appendages. 

ARCH  IV  F.  GYN.  XXVIII.  500,  Cocaine  in 

plastic  surgery.  XXXI.     380,    Apparent 

effects  of  Cocaine. 

CENTRALS.  F.  GYN.  X.  392,  Local  in  peri- 

neal  operations.  XI.  751,  Heart-puncture 
in  chloroform  narcosis. 

ANTISEPTICS. 

BRIT.  MED.  JOUR.  1887,  I.  155,  Poison- 

ing by  Corrosive  Sublimate  ;  451,  674,  Dru- 
mine ;  782,  Antiseptic  dressing ;  1124,  Corrosive 
Sublimate  in  intra-uterine  irrigation.  1887, 
II.  365,  Tissue  resistance  and  antiseptism ; 
729,  Antiseptic  duels ;  946,  Eucaline  antiseptic 
poultice  ;  1387,  Sodium  silico-fluoride.  1888, 

I.  148,    Acidified    corrosive    sublimate ;  150, 
Comparison  of    chlorides,   nitrates,  and  sul- 
phates ;    157,    Antipyrin    and    creolin ;    295, 
Acidified  corrosive  sublimate  ;  491,  Naphthol ; 
555,  Photoxyline  as  a  surgical  dressing ;  898, 
Chemical  incompatibility  of  antiseptic  agents ; 
970,    Chloroform   water ;    980,   Vaginal    anti- 
sepsis;   1084,  Dangers  of;  1185,  Naphthol  /3. 
1888,  II.  720,  Corrosive-sublimate  poisoning ; 
1061,  Creolin. 

LANCET.         1887,   I.   595,    lodoform.        1887, 

II.  775,  Creolin  v.  Carbolic  Acid  ;  847,  Anti- 
septic treatment  of  wounds.         1888,  I.  1142, 
Microbes  on  skin  and  suppuration  ;  1246,  New 
antiseptic  surgical  dressing. 

EDIN.  MED.  JOUR.         XXXIV.,  I.  476,  Quino- 

GLAS.  MED.  JOUR.  XXVIII.  397,  Bantock 
on  Listerism. 


DUB.  MED.  JOUR.  LXXXIL  410,  Salol. 

LXXXIII.  535,  Lepine  on. 

AMER.  JOUR.  OBS.  1886.  1076,  Asepsis  not 
Antisepsis.  1887.  335,  Poisoning  from 

sublimate;  781,  lodoform  gauze. 

CENTRALB.  F.  GYN.  X.  546,  616,  Corrosive 
sublimate ;  761,  Poisoning  from  corrosive 
sublimate.  XI.  81,  Asepsis  in  uterine 

dilators  ;  177,  lodoform  gauze  ;  249,  Corrosive 
sublimate ;  569,  585,  Corrosive-sublimate 
poisoning.  XII.  1,  lodoform  ;  65,  Corrosive- 
sublimate  poisoning ;  324,  Creolin  ;  449,  Dis- 
infection of  genital  canal. 

ARCHIV.  DE  TOO.        1887.  385,  Doleris  on. 

ANNAL.  DE  GYN.  XXIX.  255,  Antiseptic 
packing  of  peritoneum. 

ANATOMY. 

BRIT.  MED.  JOUR.  1888,  I.  44,  Fallacies  in 

frozen  sections. 
LANCET.          1887,  I.   1181,   Rare   condition  of 

veins  in  anterior  vaginal  wall.         1888, 1. 

1250,  Criticism  of  Waldeyer's  section. 
EDIN.   MED.  JOUR.        XXXTV.,  I.  425,  Labia 

minora  and  hymen. 
AMER.  JOUR.  OBSTET.          1888.  1115,  Median 

frozen  sections,  Winter. 
CENTRALB.  F.  GYN.          X.  229,  Strength  and 

action    of   abdominal    muscles.          XI.  260, 

Position  of  internal  genitals  of  nulliparae. 


BATTEY'S  OPERATION.  (See  Oophorectomy.) 

BRIT.  MED.  JOUR.  1887,  I.  576,  Compared 

with  Normal  Ovariotomy  and  Tait's  Opera- 
tion. 

AMER.  JOUR.  OBS.  1887.  1061,  Natural 

results. 

ANNAL.  DE  GYN.  XXIX.  416,  And  fibroid, 
Segond. 

BLADDER. 

BRIT.  MED.  JOUR.  1886,  I.  196,  Antiseptic 
catheter.  1886,  II.  117,  Calculus  in 

woman ;  1213,  Suprapubic  lithotomy  in  an 
elderly  woman.  1887,  I.  132,  Diagnosis  of 
tumours;  1094,  Cancer  of;  1164,  Foreign 
body  in  ;  1364,  Ibid.  1887,  II.  93,  Cystitis 
of  a  mixed  mycotic  origin ;  123,  Suprapubic 
lithotomy  in  elderly  female  by  Galgey ;  431, 
Hairpin  in  ;  993,  Lithotrity  in  a  girl  aged  11. 
1888,  I.  1,  57,  Tumours  of  the  bladder;  601, 
Electrical  illumination  of ;  645,  Sarcoma  of  ; 
775,  Leiter's  endoscope  in  treatment  of  vesical 
disease ;  785,  Value  of  electric  illumination  of ; 
1059,  Sloughing  of;  1059,  Sarcoma  of;  1247, 
Electric  illumination  of.  1888,  II.  621, 
Pessary  for  prolapse  of. 

LANCET.  1886,  II.  165,  Foreign  bodies;  252, 
Calculus  removed  per  urethram  by  Bout- 
flower.  1887,  I.  332,  Alleged  toxic  effects 
of  cocaine  on.  1887,  II.  65,  Suprapubic 

cystotomy,  by  Jones,  for  papilloma ;  561, 
Cystotomy,  by  Collis  Barry,  in  advanced 
vesical  cancer;  1111,  Removal  of  tumour  of, 
by  Gibbons  and  Parker  ;  1164,  Primary  cancer 
of.  1888  I.  275,  Etiology  of  vesical  tum- 
ours ;  347,  Effects  of  rapid  emptying ;  505, 
607,  Ibid.,  correspondence;  763,  Diagnosis  of 
tumour  by  electroscopic  cystoscope ;  949, 
Electrical  illumination  ;  1002,  Ibid.  1888, 
II.  24,  Diagnosis  of  obscure  disease  by  electric 
illumination. 

EDIN.  MED.  JOUR.  XXXI.,  II.  734,  965,  Re- 
tention of  urine  from  an  unusual  cause ;  1177, 
Artificial  vesico-vaginal  fistula  for  cure  of 
chronic  cystitis.  XXXIII.,  I.  173,  Exfolia- 
tion of  entire  mucous  membrane.  XXXIII., 
II.  1009,  Treatment  of  hydrocele. 

GLAS.  MED.  JOUR.  XXV.  412,  Diag- 

nosis of  tubercular  disease  of  the  urinary 
organs. 


686 


APPENDIX. 


DUB.  MED.  JOUR.  LXXXII.  147,  Etiology 
and  treatment  of  cystitis. 

AMKlt.  JOUR.  OBS.  1886.  60,  Frequent  mic- 
turition; 267,  Epithelioma;  489,  Ibid.;  !>29, 
Emmet's  button-hole  operation ;  993,  Ulcers 
of  ;  1218,  Epispadias.  1887.  895,  Ulcers  of 
bladder;  Ilia,  Cystitis  in  women.  1888. 
72,  Ligation  for  eystocele  ;  350,  402,  Suppura- 
tive  exfoliative  cystitis;  407,  Fibrinous  cast 
from ;  1006,  Injury  to,  during  laparotomy, 
Siinger. 

ARCH IV  F.  GYN.  XXIX.  53,  Ulcer. 

XXXII.  465,  Injury  to,  during  laparotomy, 
Hanger. 

CENTRALB.  F.  GYN.  X.  189,  Cystitis  and 
irrigation ;  341,  Tumours.  XI.  404, 

Tumours. 

VOLK.  SAM  ML.  Nos.  267,  268,  Tumours  and 
their  treatment,  Kiister. 

ARCH  IV.  DE  TOO.  1886.  654,  Cystocele  with 
stone. 

BLOOD. 

BRIT.  MED.  JOUR.  1886,  I.  998,  The  jugular 
vein  in  chloro-antemia.  1887,  I.  562,  In- 
adequate treatment  of  anaamia.  1887,  II. 
1184,  Faecal  anaemia  in  girls  and  young 
women.  1888,  I.  688,  The  anaemia  of 
puberty. 

LANCET.  1887, 1.  286,  The  blood  in  leukaemia ; 
540,  Hypometric  injections  in  acute  anaemia. 

1887,  II.  1003,  Anaemia  or  chlorosis  of  girls. 

1888,  I.  1081,   Etiology  and  classification  of 
the  anaemia  of  puberty. 

DUB.  MED.  JOUR.  LXXXI.  383,  Chloroform 
as  a  haemostatic. 

CENTRALB.  F.  GYN.  X.  494,  Salt-water  in- 
jection in  acute  anaemia. 

BROAD  LIGAMENT. 

BRIT.  MED.  JOUR.        1887,  I.  782,  Tumour  of. 

LANCET.  1886,  II.  1143,  Shortening  of  round 
ligaments.  1888,  I.  72,  Phlegmon  of. 

EDIN.  MED.  JOUR.  XXXII.,  I.  272,  Cyst  of. 
XXXII.,  II.  938,  Cyst  of. 

AMER.  JOUR.  OBS.  1886.  618,  Congenital 
deficiency  of  ;  838,  Ovary  and  Tube  from  cellu- 
litic  contraction  of ;  1273,  Cyst.  1887.  178, 
Fibroid  of.  1888.  201,  Fibro-sarcoma  ;  211, 
Primary  Myoma  of,  and  seventeen  collected 
cases ;  525,  Cyst  of  ;  611,  Cyst ;  622,  Case  of  non- 
papillary  ligamentous  cyst;  726,  Multilocular 
papillomatous  tumour ;  1287,  Papilloma. 

ARCHIV.  DE  TOO.        1887.  972,  Phlegmon  of. 


CERVIX,  ANATOMY  OF. 

AMER.  JOUR.  OBS.  1887.  1228,  Incomplete 
transverse  septum. 

CERVIX -AFFECTIONS,  OPERATIONS,  Etc. 

(For  Cancer  and  Fibrous  Tumours  of,  «ee  under 
these  A  ffections  of  the  Uterus.) 

BRIT.  MED.  JOUR.  1886, 1.  1,  Laceration  and 
trachelorrhaphy  ;  16,  209,  Laceration  of  ;  421, 
463,  524,  615,  (516,  Correspondence  on  trache- 
lorrhaphy. 1886,  II.  78,  Specimen  of 
Myxo-fibroma.  1887,  I.  109,  Twenty  cases 
of  trachelorrhaphy,  by  Beverley ;  927,  Lacer- 
ation and  its  relation  to  malignant  disease. 
1888, 1. 1274,  Electrolysis  in  catarrh.  1888, 
II.  873,  Rapid  dilatation  ;  1052,  Method  of 
dilating. 

LANCET.  1886, 1.  655,  Symptoms  of  lacer- 
ation. 1887,  I.  448,  Does  laceration  occur 
in  first  labour?  1136,  Schrceder's  operation  for 
malignant  growth  of  ;  1187,  Trachelorrhaphy, 
by  Braithwaite.  1887,  II-  19,  Dilatation  of, 
and  intra- uterine  therapeutics;  507,  Rapid 
dilatation.  1888,  I.  464,  Supra-vaginal 
amputation  for  malignant  disease,  witli  notes 
of  ten  cases,  by  Lewers ;  1248,  Chronic  catarrh 


treated  by  electrolysis.  1888,  II.  1122, 
Treatment  of  Endocervicitis  by  medicated 
bougies. 

EDIN.  MED.  JOUR.  XXXIII.,  I.  275,  Scien- 
tific dilatation  and  intra-uterine  thera- 
peutics. XXXIII.,  II.  1130,  Trachelorr- 
haphy. XXXIV.,  I.  144,  Elongatio  colli 
supra-vaginalis. 

GLAS.  MED.  JOUK.  XXVIII.  77,  Permanent 
dilatation  of  uterus;  78,  Catarrh.  XXX. 
87,  Trachelorrhaphy. 

DUB.  MED.  JOUK.  LXXXIV.  147,  Malignant 
growth. 

AMER.  JOUR.  OBST.  1886.  r)00, Laceration  with 
unique  symptoms  ;  MS,  Modification  of  trache- 
lorrhaphy ;  757,  Influence  of  lacerated  cervix  ; 
907,  Description  of  Martin's  amputation  of  the 
cervix;  1246,  1250,  Hegar's,  Schroeder's,  and 
Martin's  operations  for  ectropium,  hyperplasia, 
and  catarrh  ;  1264,  Hystero-trachelorrhaphy. 

1887.  49,    Martin's  operation  for  lacerated  ; 
523,  Necessity  for  early  operation  for  lacer- 
ation ;   736,  Laceration  viewed  obstetrically  ; 
858,    Induration ;    1076,    Treatment     during 
pregnancy ;   1097,  Rapid  dilatation  of ;   1099, 
Cancerous  degeneration  of  hyperplastic  glands  ; 
1103,  Pathology  and  treatment  of  lacerations. 

1888.  218,  Influence  of  laceration  on  origin  of 
uterine  disease ;  257,  Ibid. ;  400,  Amputation 
for  carcinoma,    Lee ;   498,  Dilatation,   septic 
peritonitis,    death ;     499,    Hystero-trachelor- 
rhaphy, septic  peritonitis,  death,   Lee ;    606, 
Death   from   peritonitis  following  trachelor- 
rhaphy ;   607,   Ibid,    following  removal  of  a 
cervical  fibroid  ;  782,  Suspicious  and  malignant 
adenoma ;    1009,    Superinvolution  of    uterus 
following  trachelorrhaphy. 

ARCHIV  F.  GYN.  XXIX.  322,  Flap-operation 
in  stenosis,  Frank.  XXXI.  4(i9,  Laceration 
of  and  uterine  disease.  XXXIII.  310,  Safe 
catgut  for  trachelorrhaphy. 

CENTRALB.  F.  GYN.  X.  95,  Cautery  in  me- 
tritis  of.  XII.  441,  Laceration. 

ZEITSCH.  F.  GEB.  UND  GYN.  XII.  229, 
One-sided  hypertrophy  of  lower  cervical  seg- 
ment ;  287,  Laceration.  XIV.  352,  Ade- 
noma. 

ARCHIV.  DE  TOG.  1886.  25,  Trachelor- 

rhaphy, by  Doleris ;  426,  Rapid  dilatation  ; 
640,  Incision  of,  for  removal  of  intra-uterine 
sessile  tumour  of  uterus ;  933,  Permanent 
dilatation  ;  1009,  Sponge  dilatation.  1888. 
569,  Thrombus  of  anterior  lip. 

ANNAL.  DE  GYN.  XXX.  241,  351,  Trachelor- 
rhaphy, by  Houzel. 

ANNAL.  DI  OSTET.  1887.  171,  Division  of, 
for  haemorrhage.  1888.  463,  Amputation 
for  erosion  and  chronic  metritis. 


DERMOID  CYSTS-OVARIAN  AND  PELVIC. 

BRIT.  MED.  JOUR.  1886,  1.  264,  Removal  of, 
during  pregnancy,  by  Thornton.  1887, 
I.  1133,  Of  ovary ;  1278,  Two  small  ovarian. 
1887,  II.  729,  Retro-rectal;  886,  Ovarian; 
1282,  With  twisted  pedicle.  1888,  I.  801, 
Expelled  per  reef  urn,  during  labour;  959, 
Mammae  in.  1888,  II.  79,  Ovarian  ;  895, 
The  mystery  of  ovarian  ;  940,  Ovarian. 

LANCET.  1886,  I.  350,  Discussion  on  ;  386, 
Referred  to  in  Bland  Sutton's  Evolution  in 
pathology  ;  920,  In  girl.  1886,  II.  1080, 
Removed  by  Malias.  1888,  I.  880,  Mamma; 
in  ;  979,  Expulsion  per  rectum  during  labour. 

EDIN.  MED.  JOUR.         XXXIII.,  I.  471,  Denti- 

DUB.  MED.  JOUR.  LXXXVI.  71,  Compli- 

cated by  Parotitis. 

AMER.  JOUR.  OBSTET.  1886.  13,  55,  Of 
both  Ovaries ;  274,  Specimen  with  pyosal- 
pinx  ;  672,  With  abdominal  gestation,  gastro- 
tomy  by  Wasseige  ;  851,  Complicating  labour  ; 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    687 


1022,   In  a  child  thirty  months  old,  ovari- 
otomy by  Hooks.        1887.  176,  Double  der- 
moid,  laparotomy  by  Munde  ;    621,   Curious 
ball  of  sebaceous  matter  in  ;   645,  Of  ovary 
1275,  Ibid.        1888.  525,  Price  on  ;  526,  Ibid. 
614,  Case  of  ;   627,  Two ;   710,  Ovarian  ;   723 
Case  ;  868,  With  carcinoma  uteri ;  1197,  Case 
1205,  Ovarian. 

CENTRALB.  F.  GYX.  X.  569,  Ovarian.  XI. 
68,  Pelvic. 

ARCHIV.  DE  TOC.  1886.  145,  Of  both  ovaries 
with  a  diverticulum  in  rectum. 

DYSMENORRH02A. 

BRIT.  MED.  JOUR.  1886,  I.  1065,  Mem- 
branous. 1886,  II.  600,  Treatment  of 
Membranous.  1888,  II.  870,  Obstructive, 
and  Sterility. 

LANCET.  1886,  II.  942,  Rapid  mechanical 
dilatation  in.  1887,  I.  126,  Removal  of 
cystic  ovaries  for,  by  Wni.  Duncan.  1888, 
I.  21,  Uterine  cast  of  Dysmenorrhceal  origin  ; 
425,  Case  of  combined  phenomena  of  Dys- 
menorrhcea,  Metrorrhagia  and  Hydrorrhcea  ; 
1132,  Treatment  of  sterility  and  obstructive. 

EDIX.  MED.  JOUR.  XXXIII,  II.  945,  Mem- 
branous dysmenorrhoeal  cast.  XXXIV.,  I. 
415,  Membranous. 

GLAS.  MED.  JOUR.  XXVII.  315,  Galvanic 
cautery  in  membranous.  XXVIII.  78, 

Local  treatment  of  membranous ;  399,  Re- 
moval of  cystic  ovaries  for,  by  Wm.  Duncan. 
XXIX.  44S,  Membranous.  XXX.  421, 

Treatment  of  obstruction  and  sterility  in. 

DUB.  MED.  JOUR.  LXXXV.  297,  Treatment 
of  sterility  and  obstructive.  LXXXVI.  73, 
Discussion  on  preceding  paper. 

AMER.  JOUR.  OBS.  1886.  185,  Uterine 
dilator  in.  1888.  40,  78,  Electrolysis  v. 
rapid  dilatation  for. 

ARCHIV  F.  GYX.  XXXI.  70,  Pathological 
anatomy  of  membranous. 

CENTRALB.  F.  GYX.        X.  264,  Membranous. 
ARCHIV.  DE  TOC.        1886.448,  Membranous; 
656,  Membranous. 


ELECTRICITY. 

BRIT.  MED.  JOUR.  1887,  I.  906,  Statical  in 
hysteria ;  1017,  1075,  Electrolysis  for  uterine 
fibroma  ;  1208,  For  fibroids  ;  1272,  Apostoli's 
method  in  uterine  and  peri-uterine  affections; 
1303,  For  uterine  disease  ;  1329,  For  fibroid 
of  uterus ;  1364,  Electrolysis  for  fibroid  of 
uterus.  1887,  II.  62,  For  fibroid;  93, 

Hydro-electric  baths  in  nervous  affections ; 
116,  For  fibroid ;  134,  Ibid.  ;  423,  Ibid.  ;  699, 
Ibid.;  702,  Ibid.;  724,  Electrolysis  for  fibroid  ; 
964,  965,  For  fibroid  ;  993,  Electrolysis  for 
fibroid  followed  by  enucleation  and  slough- 
ing;  102],  For  fibroid;  1075,  1076,  Ibid.; 
1094,  For  peri-uterine  inflammation;  1130, 
1181,  1182,  1239,  Electrolytic  treatment  of 
uterine  tumours  ;  1131,  Electrical  treatment 
of  uterine  tumours  and  Sir  James  Y.  Simp- 
son ;  1255,  Treatment  of  uterine  tumours  by  ; 
1337,  Ibid.  ;  1359,  In  treatment  of  uterine 
tumours.  1888,  I.  20,  Electrolysis  for 
large  fibroid.  1888,  I.  63,  In  gynecology ; 
102,  Electrolysis  for  fibroid ;  158,  Ibid.  ;  320, 
Magneto-therapy;  356,  In  gynecology;  368, 
Electrical  therapeutics  ;  439,  For  fibroid  ;  493, 
Ibid.  ;  547,  Ibid.  ;  557,  Apostoli  and  electro- 
lysis ;  614,  Electrolysis  for  fibroid ;  654,  A 
new  device  in  electrolysis ;  665,  Electrolysis 
for  fibroids ;  798,  Ibid,  and  subsequent  Hys- 
terectomy, by  R.  T.  Smith ;  799,  Action  of 
constant  current  on  fibro  -  myomata  ;  995, 
1012,  For  diseases  of  the  uterus  ;  997,  Electro- 
lysis for  fibroids ;  998,  For  hydrosalpinx  ; 
1065,  For  uterine  myomata ;  1085,  For  dis- 


eases of  the  uterus ;  1137,  In  gynecology ; 
1274,  Electrolysis  in  gynecology;  1274, 
Electrolysis  in  chronic  cervical  catarrh  ;  1274, 
Electrolysis  in  some  chronic  uterine  affec- 
tions ;  1274,  1384,  Constant  current  in  gyne- 
cology ;  1300,  For  fibroid  ;  1362,  Apostoli's 
treatment  of  fibroids;  1376,  Ibid.,  notes  on 
three  cases ;  1388,  Electrolysis  in  uterine  dis- 
ease ;  1410,  Discussion  on  Electrolysis  at  the 
London  Obs.  Soc.  1888,  II.  79,  For 

fibroid;  83,  Article  on  the  Discussion  on 
Electrolysis ;  102,  Apostoli's  treatment  of 
fibroids;  152,  The  Apostoli  treatment  in 
Italy ;  1412,  Electrolysis  for  fibroid. 

LANCET.  1887, 1.  103,  Medication  by  Electro- 
lysis ;  867,  Use  of  thermopile  and  secondary 
batteries  for  producing.  1887,  II.  158, 
Electrolysis  in  gynecology  ;  324,  For  fibroid  ; 
978,  Effect  of  Faradisation  on  urinary  nitro- 
gen. 1888, 1.  379,  Electrolysis  for  fibroids  ; 
446,  Electrolysis  ;  674,  For  fibromata ;  1021,. 
Endoscopy  by  electric  light ;  1248,  Electro- 
lysis in  gynecological  practice ;  1249,  For 
uterine  myomata ;  1327,  Endoscopic  illumi- 
nation. 1888,  II.  19,  In  gynecological 
practice;  24,  Electrical  illumination  of 
bladder;  103,  153,  Remarks  on  use  in  gyne- 
cology; 363,  In  treatment  of  uterine  and 
other  pelvic  disease;  1034,  Oophoralgia 
treated  by  Faradisation ;  1221,  Apostoli  and 
his  work. 

EDIN.  MED.  JOUR.  XXXIII.,  I.  87,  Applica- 
tion to  gynecology ;  88,  Chemical  galvano- 
puncture  in ;  470,  Patient  treated  by 
Apostoli's  method  for  fibroid.  XXXIIL, 
II.  670,  688,  For  fibroid  ;  1059,  In  atrophy 
of  mammary  gland.  XXXIV.,  I.  275, 
Demonstration  of  action  of  galvanic  currents, 
on  tissue ;  566,  Dangers  of  galvano-puncture 
in  pelvic  tumours ;  567,  The  new  methods  of 
electrotherapy  in  their  bearings  on  gyne- 
cological surgery. 

GLAS.  MED.  JOUR.  XXVI.  320,  Faradisation 
of  uterus  as  a  hsemostatic  agent.  XXIX. 
83,  Demonstration  of  apparatus ;  82,  For 
fibroid ;  530,  Xotes  on  forty  cases  treated  by 
Apostoli's  method.  XXX.  419,  Electrolysis 
in  uterine  flexions ;  421,  Treatment  of  peri- 
uterine  phlegmasia  by. 

AMER.  JOUR.  OBS.  1886.  197,  In  minor 
gynecology  ;  448,  Xegative  galvano-puncture 
for  peri-uterine  hsematocele ;  619,  Hsemato- 
salpinx ;  621,  Pyo-salpinx ;  1087,  Tait  on 
Faradisation  ;  1228,  Electrolytic  puncture  for 
areolar  hyperplasia.  1887.  Ill,  Intra- 
uterine  electrolysis  for  chronic  metritis  and 
endometritis ;  113,  For  fibroids ;  253,  376, 
For  fibroid,  fifty  cases;  290,  Electrolysis  for 
fibroids;  406,  Value  of;  881,  Apostoli's 
method  of  electrolysis ;  1059,  Xew  uses  of  ; 
1102,  Xew  method  for  fibroids  ;  1104,  Electro- 
lysis for  tumours  of  breast.  1888.  270, 
For  fibroid;  384,  Ibid.;  561,  And  uterine 
displacements ;  643,  Galvanic  for  fibroid, 
fifteen  cases ;  806,  Fibroid  treated  by 
Apostoli ;  820,  Value  of  Electrolysis ;  1053, 
The  dangers  of  galvano-puncture  in  pelvic 
tumours ;  1057,  Xew  methods  of  electric 
therapy  in  their  bearing  on  gynecological 
surgery. 

CEXTRALB.  F.  GYX.  X.  58,  And  hwmatocele ; 
188,  In  gynecology.  XII.  313,  In  gyne- 

cology. 

ARCHIV.  DE  TOC.  1886.  760,  Intra-uterine 
galvano-cautery  for  metritis  and  endometritis. 
1888.  739,  And  uterine  polypus. 

AXXAL.  DI  OSTET.  1888.  170,  For  fibroid  ; 
272,  Failure  of,  for  fibroid. 

EXAMINATION. 

BRIT.  MED.  JOUR.  1886,  II.  285,  Abdominal 
palpation  in  obstetrics ;  602,  Abdominal  pal- 


688 


APPENDIX. 


pation  as  a  means  of  diagnosis ;  1033,  Alleged 
improper. 

EDIN.  MED.  JOUR.  XXXII.,  II.  903,  Vulliet's 
method  of  dilating  the  uterine  cavity  for  in- 
spection. XXXIV.,  I.  381,  New  method  of. 

GLAS.  MED.  JOUK.  XXIX.  173,  Extra-peri- 
toneal exploratory  incisions;  536,  Ibid.,  in 
the  iinea  alba. 

AMER.  JOUR.  OBS.  1886.  1229,  Vulliet's 
method  of  dilating  the  uterine  cavity  for  in- 
spection. 1887.  221,  Palpation  of  pelvic 
organs. 

CENTRALB.  F.  GYN.  X.  154,  Necessity  of 
thorough  examination  of  the  genitals  in 
bleeding  from  uterus.  XII.  6,  103,  Extra- 
peritoneal  exploratory  incision,  Bardenheuer ; 
177,  Rectal  examination  by  kolpeurynter ; 
337,  New  method  of ;  471,  Diaphanoscopic 
examination  of  genitals. 


FALLOPIAN  TUBES,  ANATOMY  AND 
AFFECTIONS  OF. 

BRIT.  MED.  JOUK.  1886, 1.  66,  Inflamma- 
tion ;  457,  Tubercular  disease  ;  543,  Case  of 
hydrosalpinx ;  710,  Specimen  of  haemato- 
salpinx ;  737,  Diagnosis  of  distension  ;  821, 
Diagnosis  between  distension  of  the  tubes  and 
fibro-myoma  of  the  uterus ;  1215,  Dangers 
from  diseases  of  uterine  appendages  in  child- 
bed. 1886,  II.  78,  Specimens  of  malforma- 
tion ;  154,  Salpingectomy,  by  Murphy ;  691, 
Papilloma  and  relation  of  tubal  disease  to 
hydro-peritoneum.  1887,1.  825,  Pathology 
of  chronic  inflammation  of  ;  947,  Canalisation 
and  catheterisation  of  the  Fallopian  tube ; 
1211,  Unsatisfactory  results  of  unilateral  re- 
moval. 1887,  II.  673,  Inflammatory  con- 
dition of  ;  886,  Hsematosalpinx.  1888,  I. 
249,  Hsematosalpinx  with  cystic  disease  of 
the  ovary ;  249,  Hydrosalpinx  and  Blood  cyst 
of  the  ovary ;  35(5,  Tubercular  pypsalpinx  ; 
416,  Papilloma  of  tubes  and  ovaries ;  907, 
Case  of  Pyosalpinx  ;  958,  Primary  cancer  of ; 
998,  Electricity  for  hydrosalpinx ;  1010,  Glands 
of,  and  their  function.  1888,  II.  828,  The 
first  operation  on ;  933,  Double  pyosalpinx 
cured  by  aspiration  ;  1023,  Pyosalpinx  or  sup- 
purating parovarian  cyst ;  1222,  Salpingitis. 

-LANCET.  1886,  I.  548,  Tubercular  disease; 
744,  Specimen  of  haeiuatosalpinx  with  ovarian 
cyst.  1886,  II.  67,  Chronic  inflammation  ; 
399,  Laparotomy  for  hydrosalpinx,  by  Jones  ; 
406,  Diseases  of  uterine  appendages  ;  728,  976, 
Papilloma  of,  and  relation  of  hydro-peri- 
toneum to  tubal  disease ;  744,  Hsematosal- 
pinx  with  ovarian  cyst ;  774,  Three  cases  of 
pysosalpinx ;  869,  Lawson  Tait  on  general 
principles  involved  in  operation  for  removal. 
1887,  I.  Lawson  Tait  on  chronic  inflammatory 
disease  of ;  938,  Morbid  anatomy  of ;  982,  Fre- 
quency of  pathological  conditions  of  ;  1186, 
Tubo-ovarian  cysts.  1887, 1.  117,  Discussion 
on  tubo-ovarian  cysts ;  425,  On  extirpation 
of.  1888, 1.  372,  Specimens  of  papilloma  ; 
879,  Malignant  disease  of ;  979,  Glands  and 
their  functions.  1888,  II.  Double  tuber- 

cular pyosalpinx,  laparotomy,  by  Bull. 

:EDIN.  MED.  JOUR,      xxxi.,  n.  1177,  Atresia 

with  hypertrophy  of  muscular  walls. 
XXXII.,  I.  167,  Series  of  diseased  ;  174,  In- 
flammation of  lining  membrane ;  463,  Is 
disease  of  the  uterine  appendages  as  frequent 
as  represented?  XXXII.,  II.  653,  Ibid.; 
937,  Diseased  uterine  appendages.  XXXIII., 
II.  755,  Uterine  appendages  with  hydro-sal- 
pinx ;  756,  Tubes  and  ovaries  from  double 
hydro-salpinx  ;  809,  847,  Tubal  distension  and 
stricture. 

GLAS.  MED.  JOUR.  XXIX.  89,  Are  tubes 
and  ovaries  to  be  sacrificed  for  salpingitis  ? 

J)UB.  MED.  JOUR.        LXXXIL  146,  Of  a  girl. 


LXXXIII.  287,  Report  on  tubal  disease. 
LXXXVI.  2.ri3,  Removal  of  right  uterine  ap- 
pendage, by  Purefoy  ;  456,  An  abdominal  sal- 
pingotomy  in  the  last  century. 

AMER.  JOUR.  OBS.  1886.  75,  Hydrosalpinx 
diagnosed  as  extra-uterine  pregnancy ;  200, 
Stenosis  followed  by  muscular  hypertrophy  ; 
204,  Two  tumours ;  292,  Hydro-  and  pyo- 
salpinx with  follicular  degeneration  of 
ovaries ;  292,  Complicated  case  of  Hydro- 
and  pyo-salpinx  ;  321,  Diseases ;  408,  Double 
hydrosalpinx ;  468,  Salpingitis ;  409,  Pyosal- 
pinx ;  470,  Extirpation  of  right  tube,  by 
A.  Martin ;  505,  Pyosalpinx  ;  532,  Salpingo- 
tomy ;  561,  Is  disease  of  the  uterine  append- 
ages as  frequent  as  has  been  represented  '.'  001, 
Specimen  of  double  pyosalpinx ;  609,  Double 
pyosalpinx  with  abscess  of  one  ovary;  613, 
Case  of  Hegar's  operation  for  disease,  Lee  ; 
618,  Hydro-salpinx  with  congenital  deficiency 
of  tubes  and  broad  ligaments;  838,  Ovaries 
and  tubes  from  case  of  salpingitis ;  947, 
Frequency  of  disease  of  uterine  appendages  ; 
1169,  Tubo-ovarian  abscess  ;  1273,  Pyosalpinx 
with  cyst  of  right  broad  ligament  and  abscess 
of  ovary.  1887.  59,  Hsematosalpinx  ;  65, 
Pyosalpinx  ;  105,  Ibid,  and  Ovarian  abscess  ; 
141,  Chronic  salpingitis,  tubo-ovarian  cyst; 
186,  Pyosalpinx  of  gonorrhteal  origin ;  304, 
Hydrosalpinx  ;  317,  Etiology,  pathology  and 
classification  of  salpingitis;  421,  Double  pyo- 
salpinx and  cystic  degeneration  of  ovary  ;  478, 
Results  of  unilateral  removal  of  uterine  ap- 
pendages ;  497,  Necessity  of  complete  removal 
of  uterine  appendages ;  535,  Double  pyo-sal- 
pinx with  co-existing  ovarian  cystoma  on  both 
sides ;  669,  A  laparo-salpingotomy  in  1784  ; 
751,  Pyosalpinx;  867,  Ibid,  and  puerperal 
fever ;  1002,  Frequency  of  pathological  con- 
ditions ;  1045,  Are  tubes  and  ovaries  to  be 
sacrificed  in  all  cases  of  salpingitis?  1120, 
Tubo-ovarian  cysts ;  1282,  Photograph  of  dis- 
eased tubes  and  ovaries ;  1310,  Diseases. 
1888.  122,  Interstitial  salpingitis ;  201, 
Hydro-salpinx ;  322,  Hsematosalpinx ;  368, 
Laparotomy  for  haamatosalpinx,  Douglas ; 
485,  Martin's  method  of  operating  in  high- 
seated  abscesses  involving  the  ovaries,  tubes, 
and  intestine ;  525,  Double  hydrosalpinx ; 
525,  Uterine  fibroid  with  double  pyosalpinx  ; 
632,  Specimens  of  inflammatory ;  633,  Pus 
tubi ;  726,  Specimen  of  hydrosalpinx ;  872, 
Removal  per  vaginam,  Byford  ;  i'42,  Hsema- 
tomasalpinx ;  1275,  Double  pyosalpinx  ;  1275, 
Ibid,  and  cystic  ovaries. 

ARCHIV  F.  GYN.  XXIX.  97,  Pyosalpinx 

due  to  tuberculosis  ;  327,  Extirpation 
of,  Gusserow ;  328,  Diseases  of ;  329,  Clinical 
observations  on  extirpation  ;  330,  Relation 
of  uterine  mucous  membrane  to  diseases  of 
uterine  appendages.  XXX.  119,  Two  cases  of 
catheterisation.  XXXI.  265,  Primary  tuber- 
culosis. XXXII.  165,  Operatii  m  for  removal 
of  pyosalpinx,  Gusserow  XXXIII.  -~,  Diag- 
nosis of  early  stages  of  chronic  salpingitis. 

ZEITSCH.  F.  GEB.  UND  GYN.  XIII.  293, 
Tubal  disease ;  339,  Relation  to  disease  of 
uterine  mucous  membrane. 

CENTRALB.  F.  GYN.  X.  25,  Salpingotomy, 

Leopold  ;  29,  Hydrosalpinx  operation, 
Leopold  ;  157,  Salpingitis  with  gonococci, 
extirpation,  Mestermark  ;  106,  Fallopian 
tube  in  inguinal  hernia ;  347,  Tube  diseases  ; 
601,  Primary  sarcoma  of.  XI.  71»0,  Lapar- 
otomy for  hasmatometra  and  hiematosalpinx, 
Trzebicky.  XII.  345,  Carcinoma  ;  865, 

Palpation  of  diseased. 

ARCHIV.  DE  TOO.  1887.  331,  Tuberculosis  ; 

803,  Inflammation  of  uterine  appendages. 

ANNAL.  DE  GYN.  XXVIII.  3-21 ,  Inflammation 
of  tubes  and  ovaries.  XXX.  108,  Lapar- 

otomy  for  salpingitis  and  ovaritis,  Terrillon. 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    689 


FISTULA. 

BRIT.  MED.  JOUR.  1887, 1.  1180,  Treatment 
of  vaginal.  1887,  II.  13,  Rarer  forms  of 

rectal ;  210,  Cocaine  in  operation  for  anal ; 
930,  Best  method  of  treating  extensive  vesico- 
and  recto-vaginal  fistulfe.  1888,  II.  818, 

New  operation  for  vesico- vaginal,  by 
Champneys. 

LANCET.  1887,  I.  1136,  Treatment  of  Vesico- 
vaginal  and  vesico-uterine.  1887,  II.  490, 

Uretero  genital.  1888,  II.  718,  New 

operation  for  vesico- vagina],  by  Champneys. 

GLAS.  MED.  JOUR.          "XXX.  343,  Fiscal. 

DUB.  MED.  JOUR.  LXXXIII.  419,  Reparative 
treatment  of  graver  forms  of  vesico-vaginal. 
LXXXIV.  14S,  Discussion  on  preceding  paper. 
LXXXV.  381,  Priority  in  flap-splitting. 

AMER.  JOUR.  OBS.  1886.  291 ,  Vesico-vaginal; 
831,  Vulvo-rectal  from  violence  during  first 
coition  ;  1100,  Operation  for  recto- vaginal. 
1887.  50,  Urinal  for  use  in  vesico-vaginal  ; 
224,  Thirty-five  operations  for  urinary, 
Hochlmann. 

ARCH  IV  F.  GYN.  XXVIII.  490,  Recto- 

vaginal.  XXIX.  315,  Vesico-vaginal  fistula 
operation  Rydygier.  XXXIII.  270,  One- 

hundred-and-f orty  vesico-uterine,  Neugebauer. 

CENTRALB.  F.  GYN.  X.  125,  Colo-utero- 

vaginal.  XI.  297,  Function  of  ureter  in 

recto-vesico-vaginal  ;  o29,  Nephrectomy  for 
ureter  fistula.  XII.  207,  Recto- vaginal ; 

377,  Yesico-vaginaJ  combined  with  vesico- 
cervical. 

ARCHIV.  DE  TOO.  1887.  297,  Treated  by 

chlorine  water. 

ANNA!,.  DE  GYN.  XXV.  245,  Vaginismus 

and  urethro- vaginal.  XXIX.  408,  Vesico- 

utero-vaginal  and  ulceration  of  part  of  ureter. 

ANNAL.  DI  OSTET.  1886.  204,  402,  Kolpo- 
kleisis  in  extensive,  Morisani. 


GONORRHCEA. 

BRIT.  MED.  JOUR.  1886,  I.  201,  Gonorrhoea 
in  the  Female.  1887,  I.  035,  "  Amykos  " 

in  ;  1133,  Thallin  in.  1887,  II.  93,  Gonorr- 
hoeal  peritonitis  ;  854,  Diagnostic  value  of  the 
gonococcus  ;  911,  Gonorrhceal  cutaneous 
metastases,  prophylaxis  of  gonorrhoea. 
1888,  I.  11S5,  General  gonorrhoeal  infection  ; 
1340,  Gonorrhceal  ophthalmia.  1888,  II. 

190,  Latent  ;  1299,  Compound  gonorrhoeal 
infection. 

LANCET.  1887,  I.  542,  Salicylate  of  soda  in 

Gonorrhoea  ;  790,  Practical  value  of  the  gono- 
coccus. 1887, 11.1151,  Cocainein.  1888,1. 
591,  Treatment  by  antrophores  (i.  e.  medicated 
soluble  bougies) ;  745,  Ibid.  ;  1017,  Practical 
treatment  of  ;  1304,  Spinal  cord  affection  from. 
1888,  II.  341,  Creolin  in;  392,  Thallin  in; 
418,  Rational  treatment :  437,  Thallin  in. 

EDIN.  MED.  JOUR.  XXXI.,  II.  1092,  In  the 

female.  XXXII.,  II.  004,  Spurious;  901, 

Fluid  extract  of  kava  kava  f or.  XXXIII., 
II.  959,  The  gonococcus. 

GLAS.  MED.  JOUR.  XXVII.  238,  Gonorrhceal 
rheumatism.  XXIX.  535,  Healed  by 

injections  of  oil  of  iodoform. 

DUB.  MED.  JOUR.  LXXXII.  94,  Gonorrhceal 
rheumatism. 

AMER.  JOUR.  OBS.  1886.  988,  Relation  to 
puerperal  disease.  1887.  1300,  Mixed 

gonorrhoeal  infection;  1301,  Relations  to 
generative  process.  1888.  1188,  Specimen 

of  ovaries  and  oviducts  diseased  by  gonorrhoeal 
infection. 

ARCHIV  F.  GYN.  XXXI.  448,  Mixed  gonor- 

rhoeal infection  in  the  wife  ;  449,  Relation  to 
generative  process.  XXXII.  322,  Chronic. 

CENTRALB.  F.  GYN.  X.  79,  In  women. 

XI.  125,  Infection  in  women  ;  477,  Gonorrhceal 
vaginitis  and  endometritis  ;  528,  Site  of  gonor- 

2  x 


rhceal  infection ;  720,   Gonorrhceal  vaginitis 
and  endometritis.  XII.  373,  Latent  and 

chronic  in  women  ;  503,  In  women. 
YOLK.      SAMML.  No.      279,      Gonorrhosal 

infection. 


HERMAPHRODITISM. 

BRIT.  MED.  JOUR.  1887,  II.  619,  Hypo- 

spadias  in  the  female.       1888,  I.  91,  Case  of  ; 

223,    Or    hypospadias  ;    416,     Complex    and 

vertical  ;  1015,  Case  of. 
LANCET.  1886,  I.  290,  References  in  Bland 

Button's    '  Evolution   in    Pathology  ;  '    1223, 

Spurious.        1887,  I.  371,  Complex. 
AMER.  JOUR.  OBS.        1886.  931,  Parmly  on. 
ARCHIV    F.   GYN.  XXXIII.   311,   Pseudo- 

(masculine). 
CENTRALB.  F.  GYN.  X.  SO,  Pseudo-  ;  144, 

Epispadias  ;  659,  Reuter  on. 
ZEITSCH.  F.  GEB.   UND  GYN.  XII.  117 

Female  epispadias. 

HYMEN. 

BRIT.  MED.  JOUR.  1887,  II.  1282,  Nature 

of.  1888,    II.     870,     Imperforate     and 

Amenorrhcea;  991,  Labour  completed  at  full 

time  without  rupture  of  ;  1160,  Imperforate  ; 

1370,  Hypertrophied. 
LANCET.      '      1886,  II.  1171,  Imperforate,  with 

retention  of  menstrual  fluid.  1888,  II. 

899,  In  pregnant  female. 
EDIN.  MED.  JOUR.  XXXIV.,  I.  425,  Labia 

minora  and  hymen. 
DUB.  MED.  JOUR.          LXXXV.  521,  .As  a  proof 

of  virginity. 
AMER.  JOUR.  OBS.          1886.  481,  Imperforate. 

1888.  1120,  Case  of  conception  and  occluded. 
ARCHIV  F.    GYX  _      XXIX.  284,  Congenital 

cyst  of.  XXXII.  159,  Cysts  in  hymen  of 

new-born. 


CEXTRALB.  F.  GYN. 

in  occluded. 
ARCHIV.   DE   TOO. 

imperforation. 


XII.  219,  Conception 
1886.  32,  Congenital 


INSTRUMENTS. 

BRIT.  MED.  JOUR.  1886,  I.  16,  Continuous 
gas-cautery ;  898,  Uterine  dilators ;  1170, 
New  trocar.  1886,  II.  1040,  Uterine  re- 
positor.  1887,  I.  203,  The  dome  trocar  and 
its  uses  ;  402,  New  tube  for  uterine  lavement ; 
525,  Tents  and  their  disinfection ;  678,  New 
specula ;  750,  Improved  uterine  injector ; 
977,  Urethral  speculum ;  977,  Clamp  for  hys- 
terectomy ;  1105,  1168,  Improved  apparatus 
for  washing  out  the  bladder  ;  1278,  With  cup- 
shaped  diaphragm ;  1278,  Modification  of 
serre-nosud.  1887,  II.  73,  Surgical  search 

lamp  ;  472,  Cervical  dilators ;  514,  New  vaginal 
speculum  ;  1109,  Ibid.  ;  1157,  Dispersing  rheo- 
phore ;  1287,  New  surgical  needle  ;  1390,  In- 
strument for  removing  fsecal  lodgments  ;  1401, 
Intra-uterine  irrigator.  1888,  I.  197, 

Lange's  enema  nozzle ;  358,  Modification  of 
Tait's  trocar;  768,  New  incandescent  lamp 
cystoscope ;  1281,  New  syringe  for  rectal  in- 
jection of  glycerine.  1888,  II.  315,  New 
spiral  wire  stem  for  preserving  patency  of  cer- 
vical canal  after  operation  for  stenosis;  621, 
Pessary  for  prolapse  of  bladder ;  872,  Rapid 
dilator  of  cervix  uteri ;  1222,  Syphon  for 
washing  peritoneal  cavity;  1473,  The  ecraseur 
and  the  dividing  wire. 

LANCET.  1886,  II.  401,  Clamp  for  piles ;  535, 
New  sponge-holder  ;  1026,  New  dilator  ;  1223, 
Fomentation  bag.  1887, 1. 1094,  Torsion  for- 
ceps. 1887,  II.  705,  Apparatus  for  main- 
taining the  lithotomy  posture;  766,  "Nelaton" 
patent  valve  syringe  tube  ;  816,  New  urethral 
instruments ;  1020,  New  form  of  uterine  dila- 


690 


APPENDIX. 


tor  ;  1049,  1099,  Relation  of  ophthalmic 
disease  to  condition  of  sexual  organs.  1888, 
I.  457,  505,  Urethral  instruments  ;  528,  Patent 
enemn  nozzle ;  538,  Use  of  uterine  curette ; 
1011,  Urethral ;  1132,  Uterine  cervical  dilator  ; 
1250,  New  rectal  bougie.  1888,  II.  1026, 
Improved  simplex  enema  apparatus. 

EDIN.  MED.  JOUR.  XXXI.,  II.  784,  Con- 
tinuous or  spiral  catgut  suture  in  gyne- 
cology  ;  859,  863,  Aseptic  catheter  and  canula. 
XXXII.,  II.  658,  Imlach's  apparatus  for 
vaginal  irrigation ;  736,  Vaginal  and  intra- 
uterine  lubricator. 

GLA8.  MED.  JOUR.  XXVII.  230,  Apparatus 
for  fomentation  of  uterus  and  vagina  ;  345, 
New  uterine  dilator.  XXX.  311,  On  drain- 
age tubes. 

DUB.  MED.  JOUR.  LXXXV.  73,  Cervical 

dilator. 

AMER.  JOUR.  OBS.         1886.  68,  Cervical  dila- 
tor;   69,    Probe-pointed  scissors  for  opening 
peritoneum  ;  273,  Modification  of  Erich's  self- 
retaining  speculum;  523,    "Iridinized"  pla- 
tina  needles;  585,  Threading  needle  for  wire 
sutures ;  595,  A  practical  self-retaining  Sims' 
speculum;  621,  Uterine  applicator  and  dress- 
ing forceps  combined  ;  698,  New  instrument 
for  intra-uterine  medication  ;  734,  Hsemostatic 
forceps  for  removing  urethral  caruncles ;  811,  ' 
New  curette.         1887.  51,  Assorted  drainage 
tubes ;  146,  For  reposition  of  uterus  in  retro- 
versio-flexio ;    171,    Tenaculum     with      steel 
shank  ;  171,  Combined  tenaculum  and  conn-  \ 
terpoise    hook ;    294,    Aneurism     needle    for  j 
vaginal  hysterectomy ;  295,  Syringe  for  wash- 
ing out  abdominal  cavity ;  406,  Fine  copper- 
wire  suture  for  plastic  operations  ;  418,  'hut's 
abdominal  bandage  for  use  after  laparotomy  ; 
420,   Hard    rubber    plates  for  protection    of  '• 
abdominal  wall ;  420,  Self-retaining  tenacu-  ' 
him ;    519,   Modified  aneurism    needle ;    520,  j 
Ecraseur ;    549,  Adjustable  speculum  and  re-  I 
tractory ;  642,   Slippery-elm  tent ;  854,   Self- 
i-etaining  Sims'  speculum  ;  1009,  Juniper  cat-  ! 
gut ;  1029,  Perinea!  and  ovariotomy  cushions ; 
1280,   Tenaculum.  1888.    58,    Trachelor- 

rhaphy  scissors ;  71,  Improved  Peaslee  needle  ; 
177,  Modified  Martin  colporrhaphy  needles  ; 
177,  Improved  needle-holders ;  302,  Clamps  ' 
for  vaginal  hysterectomy ;  307,  Glass  tubes 
for  silk-worm  gut  sutures ;  394,  Jones'  needle- 
holder  ;  399,  Trachelorrhaphy  scissors ;  495,  A 
suture  apparatus  for  trachelorrhaphy ;  708, 
Needle-holder,  Hanks ;  709,  Clamp  forceps  for 
vaginal  hysterectomy ;  721,  Aseptic  two-way 
uterine  catheter;  721,  Cotton  packer;  942, 
Knife-blade  tenaculum-;  945,  Self-retaining 
speculum  ;  1272,  Counter-pressure  needle  for- 
ceps ;  1286,  Recent  modification  of  Bozeman's 
uterine  catheter  ;  1286,  Self-retaining  drain- 
age tube  for  pelvic  abscesses  opening  into 
rectum  ;  1287,  Pedicle  forceps  for  vaginal  06- 
phorectomy ;  1287,  Modification  of  Sims' 
needle-forceps ;  1307,  Delore's  flexible  blunt- 
hook;  1307,  Doh*ris'  6couvillon;  1307,  Mathieu's 
instrument  for  washing  out  the  uterus. 

CENTRALB.  F.  GYN.  X.  193.  New  leg-holder 
for  lithotomy  position  ;  209,  Leg-holder ;  398, 
Catgut  as  a  sewing  material ;  778,  Fritsch- 
Bozeman  catheter.  XI.  203,  Bath  drawers 
in  gynecology.  XII.  633,  Double  uterine 
catheter. 

ARCHIV.  DE  TOC.  1887.  980,  Double  sound 
for  intra-uterine  injection. 

ANNAL.  DI.  OSTET.  1887.  242,  New  uterine 
scoop. 

INTRA-UTERINE  MEDICATION. 

BRIT.  MED.  JOUR.         1888,  I.  907,  Ball  on. 

LANCET.  1887,  I.  793,  Fatal  results  of. 
1888,  II.  1122,  Medicated  bougies  in  treat- 
ment of  endo-metritis. 


EDIN.  MED.  JOUR.  XXXIII.,  I.  275,  Scien- 
tific dilatation  of  os  and  cervix  uteri  and 
intra-uterine  therapeutics. 

AMER.  JOUR.  OBS.  1886. 1S5,  Uterine  dilator 
in  intra-uterine  therapeutics ;  704,  Abuse  of  ; 
881,  Medicating  tubes ;  1233,  New  system. 
1887.  286,  Wilson  on ;  334,  Latest  method  of 
dilating  uterine  cavity. 

CENTRALB.  F.  GYN.  X.  124,  Tampons  and 
septicpemia ;  225,  Injection  for  endometritis. 
XI.  781,  Dilatation  of  uterus.  XII.  4(51, 
Application  of  zinc,  chlor. ;  545,  Ibid. 

ARCHIV.  DE  TOC.  1886.  426,  Rapid  dilata- 
tion of  cervix  ;  933,  Permanent  dilatation  of  ; 
1009,  Sponge  dilatation  of  uterus ;  1018,  Intra- 
uterine  tamponade. 


KIDNEY. 

BRIT.  MED.  JOUR.  1887, 1.  456,  Misplace- 
ment of;  583,  Nephrectomy  by  Schmidt ;  685, 
Stays  and  movable  kidneys  ;  1015,  Transperi- 
toneal  nephrectomy,  by  Terrier.  1887,  II. 
17,  Abdominal  Section  by  Imlach  for  renal 
hydatids;  370,  Cystic  kidneys;  1320,  1388, 
Diagnostic  value  of  haernaturia.  1888,  I. 
73,  Extirpation  for  hydronephrosis  ;  182,  On 
certain  neuralgias  simulating  renal  calculus ; 
242,  Hydronephrosis,  nephrectomy  by  Hunter ; 
303,  Hydronephrosis ;  324,  Ventral  nephrec- 
tomy by  Lucas,  for  hydronephrosis ;  356, 
Nephrotomy,  by  Verrall,  for  renal  calculus ; 
378,  Ventral  nephrectomy,  by  Hunter,  for 
hydronephrosis ;  440,  Ibid.,  by  Lucas;  502, 
Ibid.,  by  Hunter;  648,  Sarcoma  of;  747, 
Cystic  ;  763,  Nephrectomy  for  pyonephrosis  ; 
860,  Scrofulous.  1888,  II.  677,  Floating  ; 
1049,  Extirpation  of. 

LANCET.  1886,  II.  212,  Movable  kidneys  with 
pyonephrosis,  operation  by  Francis ;  221, 
Hysterectomy  and  nephrectomy,  by  Calder- 
ini ;  414,  Renal  tuberculosis.  1887,  I.  370, 
Nephro-lithotomy.  1887,  II.  66,  Nephrec- 
tomy for  hydronephrosis,  by  Elder ;  230, 
Nephrectomy  in  Belgium  ;  603,  Removal  with 
both  ovaries  by  Treves ;  956,  Action  of 
certain  drugs  on  circulation  and  secretion  of ; 
1015,  (Congenital  hydronephrosis.  1888,  I. 
369,  Pyonephrosis  due  to  obstruction ;  463, 
Possibility  of  washing  out  through  bladder  ; 
469,  Tubercular  disease  simulating  malignant ; 
674,  Cystic,  with  calculi ;  877,  Chronic  hydro- 
nephrosis, nephrectomy  by  Stanmore  Bishop  ; 
1182,  1237,  Surgical  treatment  of  renal  calcu- 

EDIN.  MED.  JOUR.  XXXII.,  I.  70,  Primary 
cancer  of ;  337,  Sarcoma  with  adherent  intes- 
tine. 

GLAS.  MED.  JOUR.  XXVI.  180,  Case  of 
double  uterus  and  one  kidney.  XXVII. 
321,  Nephrotomy  and  nephrectoray. 

DUB.  MED.  JOUR.  LXXXII.  174,  Cocain  as  a 
diuretic.  LXXXIII.  446,  Surgical  inter- 
ference. 

AMER.  JOUR.  OBS.  1886.  1221,  Nephrec- 
tomy. 1887. 1280,  Tumour.  1888.  557, 
Wandering. 

CENTRALB.  F.  GYN.  X.  I. ,  Nephrectomy,  Heil- 
brun  ;  96,  Floating  ;  361,  Nephrectomy,  Le 
Dentu.  XI.  629,  Nephrectomy  for  ureteric 
fistula,  Gusserow. 


LIVER 

BRIT.  MED.  JOUR.  1886,  I.  872,  Cholecys- 
totomy.  1886,  II.  899,  Hepatic  phle- 

botomy ;  901,  903,  Surgical  treatment  of. 
1887,  I.  1301,  Tuberculosis.  1887,  II.  422, 
Cholecystotomy ;  1148,  Two  cases  of  chole- 
cystotomy  ;  1283,  Hydatid  tumour  cured  by 
incision  ;  1333,  Hydatid  tumour,  tapped  and 
drained  across  the  pleura!  space  ;  1333,  Extra- 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    691 


peritoneal  rupture  of  hydatid  cyst ;  133", 
Physiological  variations  in  position  and  shape. 
1888,  I.  136,  Laparotomy,  by  Cluttpn,  for 
obstruction  from  gall-stone ;  324,  Cirrhosis 
of ;  378,  Ibid. 

LANCET.  1886, 1.  296,  Cholecystotomy,  by 
Lawson  Tait.  1888,  I.  240,  Cirrhosis  of ; 
518,  Effects  of  tight-lacing  on  secretion  of 
bile;  616,  Two  cases  of  cholecystotomy,  by 
Nairne  ;  716,  Series  of  eleven  cases  of  cholecys- 
totomy, by  Lawson  Tait ;  726,  Hydatid ; 
1298,  Ibid. 


MAMM.S  (DISEASES  OF). 

BRIT.  .MED.  JOUR.  1887, 1.  436,  Reportof  the 
British  Medical  Association  on  cancer  of  the 
breast.  1887,  II.  174,  Treatment  of  mas- 
titis ;  327,  Ibid,  by  pressure.  1888,  I.  24, 
Tubercular  tumour ;  24,  Spreading  cancer  of  ; 
533,  Villous  carcinoma  of  right  breast ;  957, 
Large  sarcomatous  tumour;  1046,  1101,  Car- 
cinoma, operation  by  Macnamara ;  1277,  Al- 
veolar sarcoma.  1888,  II.  775,  Atrophy  of 
inactive  mammary  gland ;  857,  Absence  of 
mammary  gland ;  876,  Absence ;  1222,  Sar- 
coma. 

LANCET.  1887, 1.  72,  Melanotic  tumour ;  628, 
Mammary  tumours ;  780,  Treatment  of  mas- 
titis ;  1230,  1315,  Removal  of  adenoma  of 
breast.  1888,  I.  74,  Spreading  cancer  of ; 
472,  Villous  cancer  of  ;  690,  Cancer,  treated  by 
erysipelas  inoculation  ;  1258,  Modelling  clay 
in.  1888,  II.  1281,  Inflammation  and  treat- 
ment by  elastic  pressure. 

EDIN.  MED.  JOUR.  XXXIII.,  II.  1059,  Elec- 
tricity in  atrophy. 

DUB.  MED.  JOUR.  LXXXV.  13,  Treatment 
of  mammary  tumours. 

AMER.  JOUR.  OBS.  1887.  1104,  Electrolysis 
for  tumours.  1888.  503,  Very  early  removal 
of  entire  breast  for  "suspected"  cancer, 
Janvrin. 

CENTRALB.  F.  GYN.        XII.  570,  Tuberculosis. 

ARCHIV.  DE  TOO.  1888.  298,  Septicaemia  of 
mammary  origin  ;  622,  Supernumerary  mam- 
mae. 

MASSAGE. 

BRIT.  MED.  JOUR.  1886,  I.  926,  Massage  as 
a  therapeutic  agent ;  1034,  Massage  and  Assimi- 
lation. 1887,  II.  232,  For  severe  hysteria  ; 
502.  In  chronic  dyspepsia  and  sleeplessness. 
1888,  I.  1298,  Three  cases  of.  1888,  II. 
175,  Colles  on. 

LANCET.  1886,  I.  982,  Physiological  effects. 
1886,  II.  703,  795,  Sturges  on;  749,  845, 
Murrell  on  ;  750,  894,  Easton  on ;  795,  Play- 
fair  on  ;  894,  Little  on.  1887,  1. 125,  Physio- 
logical effects ;  637,  Effects  on  exhalations 
from  lungs  and  skin.  1888,  I.  S,  Limita- 
tions of  the  "Weir  Mitchell  Treatment;" 
149,  Correspondence  on ;  680,  Atkin  on  ;  921, 
As  a  curative  agent;  1128,  Severe  cases  of 
hysteria  cured  by  massage,  seclusion,  and 
overfeeding. 

EDIN.  MED.  JOUR.  XXXIII.,  I.  35,  119, 
Grant  on. 

GLAS.  MED.  JOUR.  XXX.  470,  Hiinerfauth 
on. 

DUB.  MED.  JOUR.  LXXXIII.  381,  Knight 
on. 

CENTRALB.  F.  GYN.  XI.  505,  Resch 

on.  XII.  201,  Prolapse  of  uterus  and  ;  481, 
Ibid. 

MENSTRUATION  AND  OVULATION. 

BRIT.  MED.  JOUR.  1886, 1.  114,  Exploration 
of  uterine  cavity  in  menorrhagia  ;  201, 
Retention  of  ;  539,  Sudden  death  from 
haemorrhage  into  abdominal  cavity  during  ; 
800,  Pulse  during  ;  882,  980,  Vicarious  ;  894, 


Influence  of  diabetes  on.  1887, 1.  153,  And 
phthisis.  1887,  II.  €97,  Treatment  of  the 

menopause  ;  1018,  Morphinomania  and  ;  1172, 
Metrorrhagia  at  the  age  of  puberty.  1888, 
I.  385,  Case  of  early  ;  013,  After  hysterectomy  ; 
666,  Ibid.  ;  711,  From  a  laparotomy  scar;  960, 
Precocious  puberty  with  tumour  of  right 
ovary.  1888,  II.  939,  Vicarious. 

LANCET.  1886,  I.  939,  Connection  between 

splenic  tumour  and.  1886,  II.  383,  Case  of 
early  ;  1173,  After  removal  of  uterus  with 
appendages.  1887,  I.  1227,  Occurrence  of 

menorrhagia  or  metrorrhagia  during  febrile 
state.  1887,  II.  726,  Time  of  commence- 

ment. 1888,  I.  41,  Haemorrhage  in  myx- 

oedema  ;  882,  Ovarian  tumours  and  precocious 
puberty.  1888,  II.  939,  After  removal  of 

both  ovaries ;  992,  Ibid. ;  1044,  And  the  ovaries ; 
1204,  Ibid. 

EDIN.  MED.  JOUR.  XXXI.,  II.  786,  A  new 

explanation  of ;  1173,  Relation  to  development 
of  foetus  at  term.  XXXII.,  I.  201,  263, 

Relation  to  goitre. 

GLAS.  MED.  JOUR.  XXV.  413,  New  explan- 
ation of.  XXVI.  320,  Vicarious,  simulating 
pregnancy. 

DUB.  MED.  JOUR.  LXXXII.  254,  Treatment 
of  menorrhagia.  LXXXIII.  279,  Report  on. 
LXXXV.  73,  Change  of  the  field  of  vision  in. 
LXXXVI.  130,  Effects  on  vision. 

AMER.  JOUR.  OBS.  1886.  99,  Some  facts 

learned  from  artificial  repression  ;  141, 
Vicarious,  simulating  phthisis ;  152,  Persistent 
at  seventy  ;  457,  Ovulation  during  pregnancy ; 
481,  Retention  through  imperforate  hymen  ; 
618,  Menstrual  epilepsy  ;  1263,  Persistent  after 
double  ovariotomy.  1887.  S8,  Vicarious  ; 

110,  Cause  and  purpose  of;  158,  Relation  to 
sexual  functions ;  1068,  Vicarious.  1888. 

612,  Regular,  after  Tait's  operation  ;  1138, 
Repression  of  as  a  curative  agent  in  Gyne- 
cology. 

ARCHIV  F.  GYN.  XXVIIL  158,  508, 

Lowenthal  on  E.  A.  Feoktistow's  "Some  words 
on  the  causes  and  object  of  the  menstrual 
process." 

CENTRALB.  F.  GYN.  X.  58,  In  relation  to 

development  of  ovum  ;  117,  Praecox  ;  205, 
Vicarious  from  ear ;  289,  Flesch  on.  XII. 

305,  At  three  years  old  ;  360,  After  double 
ovariotomy. 

VOLK.  SAMML.  No.  312,  Nervous  swelling  of 
skin  during  menstruation  and  menopause. 

ARCHIV.  DE  TOG.  1886.  31,  Double 

ovariotomy  and  ;  433,  Relation  of  diabetes  to. 
1887.  337,  Paralysis  and  menstrual  disorders  ; 
356,  Early  ;  667,  Report  on  ;  913,  Metrorrhagia 
at  puberty. 

ANNAL.  DE  GYN.  XXV.  178,  In  Syria. 

ANNAL.  DI  OSTET.  1886.  248,  Ovulation  in 
pregnancy  ;  392,  Ibid. 

MICRO-ORGANISMS. 

BRIT.  MED.  JOUR.  1887,11.  166,  Lawson 

Tait  on  development  of   surgery  and   germ 

theory  ;    929,   Cultivation  experiments  with 

malignant  new  growths. 
EDIN.  MED.  JOUR.  XXXI.,  II.  772,  Germ 

theory  of  disease. 
AMER.  JOUR.  OBS.  1888.  781,  In  genital 

canal  of  healthy  woman. 
CENTRALB.  F.  GYN.  X.  157,  Gonococci  in 

salpingitis.  XII.  2S1,  In  genital  canal  of 

healthy  woman. 
ZEITSCH.  F.  GEB.  UXD  GYN.         XTV.  443,  In 

vagina  of  healthy  woman. 

MISCELLANEOUS. 

BRIT.  MED.  JOUR.  1886,  I.  181,  Progress 

and  work  of  the  British  Gynecological  Society ; 
587,  The  advantage  of  straightening  the  uterus 
in  cases  of  uterine  haemorrhage ;  1053,  1095, 


692 


APPENDIX. 


1154,     Functional     disorders     of     females. 

1886,  II.  856,   Certain  operations  ;    910,  On 
certain  mooted  points  in  Gynecology  ;   1028, 
Cardiac  dilatation  at  puberty  and  its  frequent 
occurrence  in  girls ;  1224,  Report  of  Liverpool 
Hospital  for  Women ;  1253,  Summary  for  1880. 

1887,  I-  145,  On  some  pending  questions  in 
Gynecology  ;  259,  325,  370,  Evolution  in  path- 
ology; 567, 984, 114S,Exceptional  symptomsand 
rare  forms  of  disease  ;  613,  827,  Parotitis  after 
injury  to  abdomen  and  pelvis ;  1238,  Peculiar 
anomaly  of  the  sexual  organs.  1887,  II. 
77,  Tumours  of  the  umbilicus ;  376,  475,  Papers 
and  discussions  at  Brit.  Med.  Assoc.  in  1887  ; 
421,  Hydrocele  in  the  female ;  478,  Artificial 
immunity  to  septicaemia ;   509,  Hydrocele  in 
the  female  ;  672,  Ill-health  in  female  servants 
and  shop-assistants ;  912,  Hydrocele  in  female ; 
12SO,  Fatty  degeneration  of  the  heart  for  intra- 
abdominal  pressure  ;    1304,   Experiments  in 
telepathic    medication  ;    1350,    Paralysis    of 
abdominal  muscles ;  1377,   Hydrocele  in  the 
female ;  1379,  Treatment  of  habitual  constip- 
ation ;  1387,  Congenital  sacral  tumour;  1413, 
1442,  Retrospect  for  1887.            1888, 1.  132, 
Treatment   of    habitual    constipation  ;    252, 
Myxoedema  in  married  women  ;  303,  Etiology 
of  pel  vie  disease  in  women  ;  303,  Dublin  schools 
and  their  teaching ;  368,  Removal  of  a  hairpin 
from   the  peritoneum  ;    855,   Cases  of   acro- 
megaly  ;  899,  Removal  of  hairpin  from  female 
bladder  ;     971,     Micro-organisms    in    female 
genital  tract  ;    1212,  1374,  Rare  diseases  and  j 
exceptional  symptoms  ;  1387,  Extra-peritoneal 
cysts.            1888,    II.     1458,     Retrospect    of  | 
Gynecology  for  18S8. 

LANCET.  1886,  I.  19,  Recent  progress ;  86, 

130,  227,  374,  Relation  of  parotid  to  generative 
organs  ;  111,  Osteomalacia  ;  896,  Inheritance 
of  acquired  pathological  properties  ;  943, 
Photographing  the  uterine  cavity.  1886, 

II.  304,  375,  422,  470,  558,  603,  1147,  Hospital 
for  Women  in  Liverpool.  1887.  I.  82, 

Hospital  for  Women  in  Liverpool  ;  445, 
" Erythromelalgy ; "  482,  Phagocytes;  563, 
Inaugural  address  to  Obstet.  Soc.  Lond. 

1887,  II.    704,    Pathogenesis    of    disease    in 
women  ;     1239,    Alexander's    Operation     in 
Belgium.  1888,  I.     57,     163,    209,    425, 
Some  points  in  surgery  of  urinary  organs ;  72, 
Influence  of  sex  on  health  and  disease ;  880, 
Ovarian    tumours   and    precocious    puberty. 

1888,  It.  336,  Genito-urinary  surgeons. 
EDIN.  MED.  JOUR.  XXXI.,  II.  623,  Rare 

cases  of  malignant  disease  of  the  female 
sexual  organs  ;  765,  Simple  means  of  washing 
out  the  uterus ;  883, 1173,  Nature  of  secretions 
of  female  genital  organs.  XXXII.,  I.  55, 

169,  287,  Unsuccessful  Case  of  Alexander's 
operation.  XXXII.,  II.  585,'  Halliday 

Groom's  introductory  address  to  Edin.  Obstet. 
Soc.  ;  865, 938,  Clinical  teaching.  XXXIII. , 
I.  576,  Report  on  genito-urinary  diseases. 
XXXIII.,  II.  838,  Etiology  of  tumours  ;  864, 
Juniper  catgut  ;  873,  1127,  Alcoholism  in 
Gynaecology ;  933,  935,  Cases  of  myxoedema. 
XXXrV.,  I.  47,  HaUiday  Groom's  valedictory 
address  to  Edin.  Obstet.  Soc.  ;  512,  Underbill's 
Introductory  address  to  Edin.  Obstet.  Soc.  ; 
566,  Influence  of  pregnancy  on  pelvic  dis- 
ease. 

GLAS.  MED.  JOUR.  XXV.  76,  Shortening  of 
the  round  ligament.  XXVII.  314,  Alter- 

ations of  the  ganglion  of  Frankenhauser, 
(cervico-uterine  ganglion)  in  simple  and  para- 
metric atrophy ;  408,  Gynecological  cliniques 
of  Vienna  and  Berlin. 

DUB.  MED.  JOUR.  LXXXI.  18,164,  Recent  pro- 
gress in  Gynecology.  I.TTKTCn,  92,  Climac- 
teric diabetes.  LXXXTV.  422,  472,  Report 
on  Rotunda  Hospital  for  three  years  to  3rd 
Nov.  1886.  LXXXV.  381,  Priority  in  flap- 


splitting  ;  392,  Report  on  Rotunda  hospital 
for  year  ending  3rd  Nov.  1887.  LXXXVI. 

73,  Discussion  on  preceding  report. 

AMEH.  JOUR.  OBS.  1886.  187,  Local  v. 

general  treatment  in  gynecology ;  203,  Drain- 
age-tube passed  per  rectum;  310,  Methods  of 
diagnosis  ;  387,  Report  on  gynecology  in 
France ;  395,  1038,  Report  on  gynecology  in 
Germany ;  468,  A  morning  with  August 
Martin ;  548,  Diabetes  in  connection  with 
uterine  disease,  menstruation,  and  pi'egnancy; 
765,  Impressions  of  German  and  English 
gynecology ;  951,  Pressure  in  Davidson's 
syringe;  1211,  Report  on  gynecology;  1262, 
Perforation  of  uterine  wall  by  spoon  saw  ; 
1292,  Gynecological  cabinet.  1887.  501,085, 
Dry  treatment  in  gynecology ;  707,  Treatment 
of  pain  and  insomnia  from  gynecological 
causes ;  724,  Gynecology  in  France ;  984, 
Chiara's  clinic ;  1064,  Vaginal  injections  in 
Sims'  posture  ;  1091,  Drainage  per  vuf/iitant  ; 
1113,  Remote  results  of  shortening  the  round 
ligament  ;  1213,  Observations  in  Vienna. 
1888.  13,  Removal  of  vaginal  tampon  twenty- 
nine  years  after  insertion  ;  113,  187,  Chronic 
anaemia  and  wasting  in  newly  married  women; 
133,  A  new  stitch  ;  599,  Technique  of  gynaeco- 
logical surgery,  S.  Sutton ;  094,  737,  Cases  in 
practice ;  1047,  President's  address  to  American 
Gynecological  Society,  Battey  ;  1064,  Presi- 
dent's address  to  American  Association  of 
Obstetricians  and  Gynecologists,  Taylor ; 
1094,  Diseases  of  the  skin  associated  with 
sexual  disorders  in  the  female. 

ARCHIV  F.  GYN.  XXXIL  505,  Laxity  (if 

abdominal  walls.  XXXIII.  312,  Woman 
with  rudimentary  sexual  organs. 

CENTRALB.  F.  GYN.  X.  20,  Disorders  of 
early  life  ;  65,  Floating  spleen  ;  122,  Diabetes 
in  relation  to  female  sexual  organs ;  204, 
Dilatation  of  uterus  ;  297,  Clinical  notes  ;  606, 
Baths  in  women's  diseases ;  745,  Tearing  out 
of  uterus  and  destruction  of  recto-vaginal 
septum,  Schmalfnss.  XI.  70,  Genital  tuber- 
culosis ;  457,  Rubber-bags  in  gynecology  ;  033, 
841,  Atrophy  of  genital  apparatus  in  morphia 
excess;  678,  Cysts  of  mesentery;  681,  Plugging 
of  vagina ;  744,  Female  sexual  organs  and 
other  organs ;  855,  Extirpation  of  spleen, 
Orlowski.  XII.  338,  Extirpation  of 

spleen,  Liebman  ;  406,  Internal  erysipe- 
las ;  499,  Atrophy  of  genitals  in  diabetes 
mellitus. 

ZEITSCH.  F.  GEB.  UND  GYN.  XII.  262, 
Tumours  and  pregnancy. 

VOLK.  SAMML.  No.  321,  Source  and  Treat- 
ment of  bleeding  in  gynecology. 

ARCHIV.  DE  TOG.  1887.  529,  Tuberculosis  in 
early  life. 

ANNAL  01  OSTET.  1886.  178,  Abnormal  fat 
production.  1888.  408,  Diffuse  muscular 
spasm. 


NERVOUS  AFFECTIONS. 

BRIT.  MED.  JOUR.  1886,  I.  1056,  Uterine 
neuroses.  1886,  II.  130,  Intense  mam- 

mary neuralgia  ;  147,  409,  Uterine  neu- 
roses ;  546,  Tympanitis  in  hysterical  women  ; 
650,  Hysterical  apoplexy ;  780,  Hysterical 
amaurosis  ;  837,  Haematemesis  in  hyste- 
rical patients  ;  853,  Neurasthenia  ;  947, 
Asphalgesia  in  the  hysterical.  1887,  I.  64, 
Nymphomania  ;  122,  Boldo-glucine  in  nervous 
insomnia  ;  133,  Transmission  of  hysterical 
symptoms  by  means  of  a  magnet ;  905,  Statical 
electricity  in  hysteria;  1016,  Vitiligo  as  a 
symptom  ;  1228,  Prostitution  and  insanity 
(nervous  and  mental  affections).  1887,  II. 
60,  Uterine  neuroses  ;  93,  Hydro-electric  baths 
in;  126,  Rare  forms  ;  150,  Hysterical  pemphi- 
gus ;  232,  Treatment  of  severe  hysteria  ;  430, 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    693 


Antifebrin  in  ;  1071,  Hypnotism  in  hysterical 
vomiting;  1304,  Hypnotism  in  hystero-epilepsy. 
1888,  I.  40,  Antipyrin  in  nervous  drowsiness  ; 
100,  Treatment  of  epilepsy  by  antipyrin  ;  156, 
Hysteria  and  syphilis  ;  300,  Indications  of 
neurasthenia  contrasted  with  those  of  hysteria ; 
323,  Antipyrine  in  epilepsy ;  348,  Case  of 
melancholia  ;  358,  Tail's  operation,  by  Law  son 
Tait,  for  intense  hystero-epilepsy  ;  377,  Nomen- 
clature of  neurasthenic  conditions;  417,  418, 
Some  cases  of  hysteria  ;  418,  Death  with 
symptoms  of  hysteria  ;  700,  Hystero-epilepsy 
treated  by  removal  of  uterine  appendages,  by 
Imlach  ;  1007,  Cases  of  ;  1012,  Functional  eye 
symptoms  in  ;  1082,  Actual  cautery  for 
epilepsy. 

LANCET.  1886,  I.  123,  Treatment  of  hysterical 
vomiting;  351,  Hysterical  pyrexia ;  940, 
Hysterical  fever  ;  1055,  1105,  1151,  Functional 
disorders  of  females.  1886,  II.  397,  Hysteria 
or  tetanus  ;  457,  Neurasthenia  ;  686,  Hysterical 
apoplexy  ;  837,  Spontaneous  shedding  of  nails 
in  hysteria  ;  882,  Hysterical  contracture ; 
1170,  Hysterical  affections.  1887,  I.  389, 
Neurasthenia  not  hysteria  ;  924,  Psychic  and 
nervous  influences  in  disease.  1887,  II. 

577,  Hysteria  and  traumatism  ;  726,  Hystero- 
epilepsy  cured  by  a  sham  operation  ;  1112, 
Hysterical  hyperpyrexia  ;  1213,  Hystero- 
epilepsy,  treated  by  Tait's  operation.  1888, 
I.  224,  Improper  use  of  term  "hysteria;" 
236,  Hysteria;  391 ,  Neurokinesis,  Neurasthenia, 
Hysteria  ;  422,  Cases  of  hysteria  ;  423, 
Functional  neuroses  simulating  hysteria ; 
516,  583,  597,  Anorexia  nervosa  ;  613, 
Case  of  anorexia  nervosa  vel  hysterica ; 
817,  Note  on  ibid.  ;  818,  Case  of  ibid.  ;  842, 
Abdominal  pressure  in  hysteria ;  899,  949, 
1002,  Anorexia  nervosa  ;  1128,  Severe  case 
of  hysteria  cured  by  massage,  seclusion,  and 
over  -  feeding  ;  1184,  Sympathetic  nervous 
system  in  acute  disease. 

EDIN.  MED.  JOUR.  XXXII.,  II.  654,  Opinion 
of  leading  authorities  on  castration  in  mental 
and  nervous  diseases  ;  952,  Treatment  of 
hysterical  attack.  XXXIII.,  II.  1060, 

Nervous  symptoms  from  displacement  of 
uterus  and  appendages. 

GLAS.  MED.  JOUR.  XXV.  489,  Treatment  of 
neuralgia  and  painful  affections  ;  491,  Treat- 
ment of  hysteria  by  compression  of  nerves. 
XXVI.  230,  Cardiac  neurasthenia.  XXVIII. 
398,  Oophorectomy  for. 

DUB.  MED.  JOUK.  LXXXL  329,  Re- 

port on. 

AMER.  JOUR.  OBS.  1886.  135,  Dependent 

on  ovarian  displacement  ;  154,  Hystero- 
catalepsy  of  obscure  origin  ;  390,  Myelitis 
following  pelvic  cellulitis  ;  785,  Cardiac  neu- 
roses connected  with  ovarian  and  uterine 
disease  ;  863,  Hysteria  in  a  young  girl.  1887. 
223,  Reflex  gastric  neuroses  due  to  uterine 
disease.  1888.  410,  Laparotomy  for  hystero- 
epilepsy,  Lee;  435,  Oophorectomy  for  epilepsy, 
Reamy;  993,  Origin  of  psychoses  following 
operations  on  the  female  genital  apparatus ; 
1185,  Perityphlitic  abscess  originating  in 
typhlitis. 

ARCHIV  F.  GYN.  XXIX.  333,  Oophorectomy 
in  epilepsy  ;  333,  Ibid,  in  neuroses.  XXXII. 
457,  Psychoses  arising  from  operations  on  female 
genitals. 

CENTRALB.  F.  GYN.  X.  834,  Nervous 

symptoms  in  disease  of  female  sexual  organs. 
XL  418,  442,  Neuroses  in  relation  to  gyneco- 
logical operations  ;  746,  Tympanitis  in  hys- 
terical women.  XII.  50,  Functional  neu- 
roses in  female  sex  and  relation  to  sex  troubles; 
137,  Hysteria. 

ARCHIV.  DE  TOG.  1887.  289,  Castration  and; 
644,  Uterus  in  morphinomania  ;  706,  Removal 
of  ovaries  in. 


OOPHORECTOMY. 

BRIT.   MED.  JOUR.        1886,  I.  1065,  By  Edis. 

1887,  I.  122,  In  neurotic  women ;  210,  Cases 
of,  by  Hume;  1211,  Unsatisfactory  results  of 
unilateral  removal.        1888,  I.  538,  By  Lunn, 
for  uterine  fibroids ;    546,  And  the  develop- 
ment of  the  genital  tract ;  861,  Abortion  after. 

1888,  II.  77,  By  Lunn,  for  bleeding  fibroid. 
LANCET.          1886,  I.    34,    By    Roth,    first    in 

Cagliari  of  Sardinia;  353,  By  Knowsley 
Thornton,  during  pregnancy ;  963,  Removal 
of  both  ovaries,  by  Tait.  1886,  II.  453, 
Spaying  ;  470,  Ibid.  ;  557,  Ibid.  1887, 1.  26, 
By  Brown  ;  104,  For  hysteria,  by  Terrier ;  126, 
Removal  of  cystic  ovaries  for  dysmenorrhosa, 
by  Wm.  Duncan ;  183,  Use  of  the  word 
"  spaying  ; "  638,  Spaying  in  the  States  ;  876, 
Successful  removal  of  right  ovary,  by  Gervis, 
for  cystic  disease  nine  months  after  operation 
for  hydrosalpinx.  1887,  II.  603,  By  Treves, 
with  removal  of  kidney.  1888,  1.  674,  By 
Lunn,  for  bleeding  fibroid  of  uterus ;  1155, 1270, 
Removal  of  diseased  ovaries.  1888,  II.  667, 
By  M'Mordie,  of  displaced  cystic  ovary  causing 
persistent  pelvic  pain  ;  1283,  Lessons  in. 

GLAS.  MED.  JOUR.  XXVIII.  398,  In  neurotic 
affections;  398,  Is  it  curative?  399,  Of  cystic 
ovaries,  for  dysmenorrhoea,  by  Win.  Duncan. 

AMER.  JOUR.  OBS.  1886.  56,  Of  cystic 
ovaries  with  pyosalpinx,  by  Janvrin;  80, 
Case,  by  Montgomery ;  81,  Supravaginal,  for 
fibroid,  by  Montgomery  ;  137,  versus  Hysterec- 
tomy for  myofibromata ;  166,  For  ovaralgia, 
by  Goodell ;  167,  For  bleeding  fibroid,  by 
Goodell ;  277,  Rare  case  of  multiple  neuro- 
mata following  ;  483,  In  fibroids ;  613,  Case 
of  Hegar's  operation,  Lee  ;  1172,  By  Price,  for 
uterine  fibroid.  1887. 172,  Of  cystic  ovary  ; 
193,  Case,  by  Thompson ;  732,  For  hystero- 
mania.  1888.  335,  For  fibroid  ;  435,  For 
epilepsy,  Reamy ;  710,  For  fibroids ;  872,  Per 
vaginam,  Byford  ;  1115,  Castration  in  Osteo- 
malacia,  Fehling ;  1189,  A  year's  work  in, 
Goodell. 

ARCHIV  F.  GYN.  XXIX.  183,  Observations 
onj_  333,  In  epilepsy ;  333,  In  neuroses 
XXXII.  506,  In  osteorualacia,  Fehling. 

CENTRALB.  F.  GYN.  X.  40,  With  supra- 
vaginal  extirpation  of  uterus  for  fibro- 
myoma,  Vogelius ;  62,  In  uterine  myoma, 
Fraipont ;  257,  In  fibro-myoma ;  580,  Of 
small  ovaries.  XI.  698,  Castration,  Hegar. 
XII.  849,  Castration,  Willers. 

ZEITSCH.  F.  GEB.  UND  GYN.  XIII.  325, 
And  neuroses.  XTV.  106,  Myomotomy  and, 
in  fibroids,  Wehmer. 

ARCHIV.  DE  TOC.  1886.  28,  Ovario-hysterec- 
tomy,  Terrier.  1887.  289,  And  nervous 
affections  of  women ;  397,  Castration,  Her- 
gott ;  658,  By  Championniere ;  706,  In 
nervous  affections. 

ANNAL.  DI  OSTET.  1887.  155,  For  fibroids. 
1888.1,  For  fibroid,  Fasola ;  49,  Vomiting 
and  meteorismus  after. 

OVARIAN  TUMOURS,  CYSTIC. 

BRIT.  MED.  JOUR.  1886,  I.  1*3,  Ruptured, 
during  operation,  by  Aveling ;  1074,  Speci- 
men. 1887,  I.  799,  Parasites  in.  1887, 
II.  510,  Specimen  ;  1050,  Ovariotomy  for  ; 
1157,  With  twisted  pedicle;  1282,  With 
twisted  pedicle.  1888, 1.  21,  Suppurating  ; 
22,  Causing  uterine  haemorrhage ;  249,  With 
hsematosalpinx  ;  249,  Cystic  disease  of  ovary  ; 
303,  Large  inultilocular  ;  906,  In  pregnancy  ; 
960,  Associated  with  precocious  puberty. 
1888  II.  125,  Hydramnios  simulating  ;  1049, 
Specimens  ;  1049,  With  twisted  pedicle  ;  1221, 
Ibid.  ;  1395,  Papillary. 

LANCET.  1886,  I.  221,  Discharge  of  cyst  per 
rectum;  353,  Specimen  of  papilloma ;  744, 
With  mematosalpinx  ;  1162,  Recurrent;  1222, 


G94 


APPENDIX. 


Removal  of,  by  Knowsley  Thornton.  1886, 
II.  072,  Spontaneous  cure.  1887,  I-  122, 
Complicating  pregnancy;  527,  Sjxjcimen;  10S/i, 
Following  injury;  1087,  Multilocnlar  ;  1139, 
Ibid.;  1186,  Tubo-ovarian.  1887,  II.  117, 
Discussion  on  tubo-ovarian  cysts ;  417,  Re- 
port on  case  ;  1 104,  Herman  on.  1888, 
I.  74,  Causing  uterine  haemorrhage ;  829, 
Cases  of.  1888,  II.  618,  Recovery  from  ; 
007,  Removal  of  a  displaced  cystic  ovary,  by 
M'Monlie ;  1281,  Cases. 

EDIN.  MED.  JOUR.  XXXI.,  II.  788,  One 
hundred  and  twelve  consecutive  operations 
for  ovarian  and  parovarian  cysts  without  a 
.  death,  by  Lawson  Tait ;  905,  With  twisted 
pedicle.  XXXII.,  I.  272,  Enlarged  cystic 
ovary.  XXXIII.,  I.  73,  Cases.  XXXIV., 

1.  275,  435,  Pathology  of  cystic  ovaries. 
GLAS.    MED.    JOUR.          XXVIII.  899,   Cystic 

ovaries    removed    for    dysmenorrhcea,    Wm. 

DUB.  MED.  JOUR.  LXXXIII.  296,  Case; 
476,  Case.  LXXXIV.147,  Multilocular ;  151, 
Case  ;  422,  Ibid.  LXXXV.  352,  Specimen  of 
suppurating.  LXXXVI.  71,  Cases  of. 

AMER.  JOUR.  OBS.  1886.  270,  Specimen 
with  pyosalpinx  ;  4S9,  Unusual;  623,  Case; 
828,  Weighing  100  Ibs.  ;  1100,  Proliferating; 
1170,  Case;  1201,  Discovered  soon  after 
delivery;  1278,  Monocyst ;  1280,  "Bursting" 
cyst.  1887.  178,  lutra-ligamentous;  309, 
Proliferating;  310,  In  broad  ligament;  311, 
Suppurating  adenoma ;  3lL>,  Unilocular,  with 
corpus  luteum ;  734,  With  papillomatous 
degeneration  of  internal  surface ;  752,  Simu- 
lating ectcpic  gestation ;  872,  Large,  cured  by 
drainage  and  obliteration  of  cavitj  Parish  ; 
878,  With  twisted  pedicle;  1283,  Simple 
ovarian  cyst.  1888.  1,  Intra-ligamentous  ; 

02,  Multilocular  colloid  ;   528,  Case  of  trau- 
matic haemorrhage  into  an  ;  530,  Small  sup- 
purating,   so-called    ovarian    abscess ;     614, 
Diagnostic  aspiration  of ;  710,  Proliferating  ; 
711,   Intra-ligamentous;     732,   Strangulated; 
1174,  Double ;    1205,  With  a  subserous  fibro- 
myoma  of  the  cervix  ;  1307,  Multilocular. 

ARCHIV  F.  GYN.        XXXIII.  327,  Malignant. 

CENTRALS.  F.  GYN.  X.  11,  Operation  in 
Malignant;  183,  Malignant;  644,  Enderlin 
on  ;  670,  Rupture  of.  XI.  147,  Rupture 
of,  during  vomiting;  233,  Case  of;  403, 
Malignant.  XII.  238,  Ascites  in  twisting 
of  pedicle. 

ZEITSCH.  F.  GEB.  UND  GYN.  XII.  14, 
Malignant. 

ANNAL.  DE  GYN.        XXVI.  245,  False. 

ANNAL.  DI  OSTET.  1886.  108,  Torsion  of 
pedicle;  197,  206,  Operation  for  intra-liga- 
mentous,  Fasola. 

OVARIAN  TUMOURS,  SOLID. 

BRIT.  MED.  JOUR.  1886,  I.  18,  Sarcoma  of; 
18,  Double-fused  ovarian  sarcoma ;  600, 
Malignant.  1886,  II.,  Myxo-carcinoma. 

1887,  I.  1164,  Of  left  ovary.  1888,  I.  648, 
Sarcoma.  1888,  II.  79,  Sarcoma ;  1049, 
Sarcoma. 

EDIN.  MED.  JOUR.  XXXIIL,  II.  755, 

Myxomatous. 

GLAS.  MED.  JOUR.  XYTX.  79,  Peculiar 
teratoma. 

AMER.  JOUR.  OBS.  1886.  528,  Advisability 
of  operating  in  cases  of  -:alignant ;  1265, 
Fibroid  ;  1277,  Fibro-sarcon.atous.  1887. 
1187.  Papilloma;  1291,  Spindle-celled  sarcoma. 
1888.323,  Fibroma;  1197,  Sarcoma  with  half- 
twisted  pedicle. 

ARCHIV  F.  GYN.  XXXIIL  1,  Origin  of 

epithelial  tumour  of ;  327,  Malignant. 

CENTRALB.  F.  GYN.  X.  183,  Malignant; 
569,  Dermoid  carcinoma;  582,  Myxoma;  044, 
Enderlin  on.  XI.  403,  Malignant. 


ZEITSCH.    F.    GEB.    UND    GYN.          XII.  14, 

Malignant. 

OVARIES,  AFFECTIONS  OF. 
BlllT.    MED.   JOUR.          1886,  I.  264,  Piipillo- 
niata  fungating  into  peritoneum.          1887, 

I.  825,  Pathology  of  chronic  inflammation  of  ; 
1104,    Papilloma.  1887,  II.   073,    Inflam- 
matory   condition      of.  1888,     I.     410, 
Papilloma  of  tubes  and  ovaries;    1389,   Pro- 
lapse of  ovary.         1888,  II.  940,  Abscess  of, 
with  uterine  fibroid. 

LANCET.  1886,  I.  402,  Displacements;  973, 
Adenoma  of.  1886,  II.  398,  Cystic  de- 

generation ;  715,  767,  Connection  with  pul- 
monary phthisis.  1887,  I.  312,  Hernia  of 
ovary.  1888,  I.  31,  Specimens  of  jiapil- 
loma;  879,  Malignant  disease  of.  1888, 

II.  709,  Blood  calculi  in  both  ;  914,  Tubercle  ; 
1034,  Oophoralgia  treated  by  Faradisation. 

EDIN.  MED.  JOUR.  XXXII.,  I.  107,  Series 
of.  diseased. 

GLAS.  MED.  JOUR.  XXIX.  76,  Specimens 
illustrative  of. 

DUB.  MED.  JOUR.  LXXXI.  Ill,  More 

Madden  on  displacements. 

AMER.  JOUR.  OBS.  1886.  292,  Follicular 
degeneration ;  413,  Papilloma  of  the  hilum  ; 
503,  Haematoma  with  adherent  Fallopian 
tube ;  009,  Abscess  of  one  ovary  with  double 
pyosalpinx  ;  i>13,  Case  of  Hegar's  operation 
for,  Lee  ;  616,  Double  cystomaovarii  papillare, 
laparotomy,  by  Lee ;  1273,  Abscess  with  cyst 
of  right  broad  ligament.  1887.  105, 

Abscess;  1196,  Absence  of  both;  1227, 
Malignant  growths  and  surgical  treatment  ; 
1282,  Photograph  of  diseased  tubes  and 
ovaries.  1888,  111,  Diagnosis  and  treat- 
ment of  adhesions  in  prolapse;  434,  Pro- 
lapsus ;  485,  Martin's  method  of  operating 
in  high -seated  abscesses  involving  the  ovaries, 
tubes  and  intestine  ;  512,  Abscess  ;  526,  Ibid.  ; 
1188,  Specimen  of  diseased  by  Gonorrhoea! 
infection  ;  1214,  Enormous  sarcoma  implicat- 
ing both  ovaries  and  one  tube  in  a  young 
girl  ;  1274,  Abscess  ;  1289,  Sarcoma. 

ARCHIV  F.  GYN.  XXXII.  234,  Cavernous 
metamorphosis  of.  XXXIII.  329,  Encap- 
suled. 

ANNAL.  DE  GYN.  XXVIII.  201,  Terrillon  on ; 
321,  Inflammation  of  tubes  and  ovaries. 

OVARIES,  ANATOMY  AND  PHYSIOLOGY 

OF. 
LANCET.         1886,  I.   213,  The  corpus  luteum  ; 

470,  Ibid. 
DUB.  MED.  JOUR.  LXXXII.  140,  Ovaries  of 

AMER.  JOUR.  OBS.        1888.  558,  Healthy  and 

diseast'il. 
A  lit -II IV  F.  GYN.  XXXI.  327,  Healthy  and 

diseased. 
CENTRALB.  F.  GYN.  XI.  409,  Pathological 

anatomy  of  ovaries. 

OVARIOTOMY.  (&e«.  l*n"Alxlo;,,nmt  SurQtrn") 
BRIT.  MED.  JOUR.  1886,1.175,  239,  Liga- 
ture in  ;  921,  One  hundred  and  thirty -nine  cases 
by  Lawson  Tait;  1141,  1196,  1230,  Revival  of 
Ovariotomy.  1886,  II.  49,  187,  Nomen- 
clature ;  49,  89,  Revival  of  Ovariotomy ;  284, 
In  London  Hospitals ;  892,  Washing  out  the 
]>eritoneuni  in.  1887,  I.  270,  Fifty  cases  by 
Skene  Keith  ;  570,  Compared  with  Tail's  and 
Battey's  Operations  ;  901,  Child-birth  after. 
1887,  II.  20,  Unusual  form  of  adhesion  met 
with  during ;  774,  Cases  of,  by  Burton  ;  1366, 
Parotitis  after.  1888,  I.  290,  At  end  of 
seventh  month  of  pregnancy  ;  303,  By  Smyth, 
for  large  mnltilocular  ovarian  cystoma ;  326, 
Early  cases  ;  Oil,  Thirty-five  cases  by  Terrillon  ; 
1127,  By  Humans,  in  an  aged  patient ;  1100, 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    695 


Urticaria  dift'usa  vel  febrilis  after.  1888, 
11.17,  Case  by  Quicke ;  SO,  Ovariotomy  in 
age;  849,  Ibid. 

LANCET.  1886,  I.  34,  The  first  in  island  of 

Sardinia;  641,  Intestinal  obstruction  follow- 
ing; 920,  For  dermoid  cyst  in  girl;  13,  By 
Cavafy  and  Haward  ;  1281,  In  Russia.  1886, 
II.  165,  For  second  time,  by  Rivington  ;  445, 
Two  cases  by  Elder  ;  SIS,  Three  hundred  cases 
by  Knowsley  Thornton  ;  916,  Parotitis  follow- 
ing ;  1174,  Three  cases  by  Wilkinson.  1887, 
I.  215,  For  dermoid  cyst,  by  Sinclair  Steven- 
son ;  339,  Listerian  and  non-Listerian ;  1129, 
Followed  by  secondary  intra- peritoneal  hsemor- 
rhage;  1283,  Cases  by  Malins.  1887,11. 

20.3,  Forty-five  completed  cases  by  Cull  ing- 
worth.  1888,  II.  1,  Clinical  lecture  on  ; 
!.'{",  Lawson  Tait  on  preceding  lecture ;  210, 
By  Macan  ;  803,  855,  Eleven  cases  by  Culling- 
worth  ;  1100,  Aveling  and  Campbell  on. 

EDIN.  MED.  JOUR.  XXXI.  II.  837,  865,  Cases 
by  Skene  Keith.  XXXIL,  I.  273.  30*!,  Sup- 
puration of  parotids  after.  XXXIII.,  II. 
620,  762,  Fifty  consecutive,  by  Halliday- 
Croom.  XXX IV.,  I.  564,  Second  in  same 
patient,  by  Sir  Spencer  \Vells. 

GLAS.  MED.  JOUR.  XXVI.  75,  Pregnancy  after 
double.  XXIX,  172,  Terrier's  fifth  series  of 
twenty-five. 

DUB.  MEL).  J»  >UR.  LXXXIII.  476,  M'Mordie 
on.  LXXXIV.  <'>9,  Successful,  by  Ester. 
LXXXVI.  298,  Three  cases  by  Byres;  302, 
Successful  case  in  a  child,  by  Mackenzie  ;  357, 
Two  cases  by  Dempsey ;  432,  Successful,  by 
Ester. 

AMEK.  JOUR.  OBS.  1886.  65,  Followed  by 
acute  peritonitis  ;  169,  By  Montgomery  :  617, 
For  small  ovarian  cyst,  Hunter ;  629,  During 
pelvic  peritonitis,  Munde  ;  640,  With  amputa- 
tion of  uterus,  Chunn  ;  1022,  In  a  child  thirty 
months  old,  for  dermoid  tumour,  by  Hooks ; 
1034,  By  Whetstone,  for  double  tumour  with 
tubercular  peritonitis;  1043,  Statistics  of; 
1136,  Twenty-eight,  by  Helmuth  ;  1272,  During 
pregnancy,  by  Munde.  1887. 48,  Statistics ; 
•298,  A  year's  work,  Goodell ;  730,  During 
pregnancy,  by  Munde  ;  1187,  For  third  time  on 
same  patient,  Munde.  1888.  544,  Two 
cases;  941,  Typhoid  fever  following;  945, 
With  hysterectomy  and  abdominal  section, 
BaUy  ;  1028,  Double  ovariotomy  during  preg- 
nancy; subsequent  delivery  at  term;  1039, 
Second  in  same  patient,  Wells ;  10S4,  Double, 
during  pregnancy,  Potter. 

ARCH IV  F.  GYX".  XXXIL  193,  Thirty- 

seven  cases,  Szabo ;  247,  Occlusion  of  gut 
after. 

CEXTRALB.  F.  GYX.  X,  109,  By  Chiara  ;  124, 
Parotitis  after ;  177,  In  Spain;  539,  Thirty 
cases,  by  Rein  ;  619,  With  peritonitis  follow- 
ing twisting  of  the  pedicle,  Miinster.  XI. 
139,  In  pregnancy  ;  425,  With  vaginal  total 
extirpation  of  uterus,  Asch  ;  436,  Operation 
for  small  tumours,  Kiistner ;  704,  Parotitis 
after;  772,  by  Schmid.  XII.  183,  Obstruc- 
tion of  bowel  after. 

ARCHIV.  DE  TOC.  1886.  31,  Double,  and 
menstruation.  1887.  358,  Six  weeks  in 

puerperium ,  Doleris. 

AXXAL.  DE  GYX.  XXVII.  161,  By  Chalot. 
XXVin.  31,  By  Chalot. 

AXXAL.  DI.  OSTET.  1887.  352.  Two  cases, 
Kirch.  1888.  21,  64,  Cases,  by  Fasola. 

OVARITIS. 

AMER.  JOUR.  OBS.          1886.  $38,  Ovaries  and 

tubes  from  chronic. 

CEXTRALB.  F.  GYX.         X.  773,  Chronic. 
ARCHIV.  DE  TOC.         1887.  803,  Inflammation 

of  uterine  appendices. 
AXXAL.  DE  GYX.        XXX,  108,  Laparotomy  for 

salpingitis  and,  Terrillon. 


PAROVARIAN  TUMOUR. 

BRIT.  MED.  JOUR.  1888,  II.  1023,  Pyosal- 
pinx  or  suppurating  parovarian  cyst. 

LAXCET.        1886,  I.  495.  Cysts. 

EDIX.  MED.  JOUR.  XXXI.,  II.  738,  One 

hundred  and  twelve  consecutive  operations 
for  ovarian  and  parovarian  cysts  without  a 
death. 

DUB.  MED.  JOUR.  LXXXII.  146,  Unilocular 
cyst ;  147,  Ibid. 

AMER.  JOUR.  OBS.  1886.  223,  Anatomy  of 
cystic.  1887.  179,  Cyst ;  310,  Cyst  compli- 
cated with  uterine  fibroid. 

CEXTRALB.  F.  GYX.        X.  29,  Cyst. 

ARCHIV.  DE  TOC.        1887.  859,  Cyst. 

AXXAL.  DE  GYX.  XXTY,  117,  Parovarian 

cysts. 

PELVIC  FLOOR,  PROLAPSUS  UTERI. 

BRIT.  MED.  JOUR.  1886.  I.  202,  Pessary 

incarcerated  in.  1887,  I.  109,  Emmet's 

operation  for  procidentia  uteri,  Beverley. 

LANCET.  1886,  II.  989,  Xew  operation  for, 

by  Malanco.  1887,  II.  660,  Inversion,  with 
complete  prolapse. 

EDIX.  MED.  JOUR.  XXXIL,  I.  172,  Etiology 
of  prolapsus.  JUjJjJL_,_II.  1042,  Treatment 
of  prolapsus.  XXXIII.,  I.  230,  Treatment 
of  prolapse. 

AMER.  JOUR.  OBS.  1886.  158,  Successful 

case  of  Alexander's  operation  ;  188,  Causes  of 
prolapse ;  605,  Cure  of  procidentia  by  Alex- 
ander's operation  ;  995,  Alexander  -  Adam: 
operation.  1887.  1051,  Alexander's  opera- 
tion, Doleris  ;  1302,  1304,  Results  of  prolapsus 
operations ;  1303,  1304,  Prolapsus  operations. 
1888.  70,  Forcible  and  complete  prolapse  in  a 
virgin  ;  1121,  Value  of  Alexander's  operation  ; 
1185,  Vaginal  hysterectomy  for  procideutia 
with  epithelioma  of  cervix  and  vagina;  1291, 
Alexander's  operation  with  report  of  cases, 
Xewman. 

ARCHIV  F.  GYN.  XXX,  401,  Extirpation  of 

uterus  for  prolapse ;  452,  Results  of  pro- 
lapse operations ;  453,  Prolapse  operations. 
XXXIII.  313,  Vaginal  ligature  of  uterus  in 
prolapse ;  324,  Xew  operation  for  prolapse, 
Firnig. 

CEXTRALB.  F.  GYX.  X.  59,  Prolapse  oper- 
ations. Martin.  XL  277,  Alexander-Adams 
operation,  Gardner.  XII.  201,  Prolapse  and 
massage;  481,  Ibid.;  561,  Vagino  -  uterine 
ligature  in  prolapse ;  641,  Alexander- Adams 
operation  in  prolapse. 

ZEITSCH.  F.  GEB.  UXD  GYX.  XTV.  500, 

Prolapse  operations. 

ARCHIV.  DE  TOC.  1886.  22,  Alexander 

operation,  Pajot.  1887.  304,  Alexander- 

Adams  operation,  Pozzi  ;  426,  Ibid.,  Bonilly. 

AXXAL.  DE  GYX.  XXIX.  321,  Prolapse; 

XXX.  161,  321,  Prolapse. 

PELVIS,  ANATOMY  OF. 

LANCET.  1886,  II.  1131,  Dissection  of  muscles, 
by  Doran. 

PERINEUM. 

|  BRIT.  MED.  JOUR.  1886,  I.  341,  Perineor- 

rhaphy. 

i  LAXCET.  1888,  I.  219,  Complete  rupture. 

1888,  I-  876,  Extensive  destructive  ulcera- 
tion  from  rectal  obstruction  with  caries  of  5th 
lumbar  vertebra. 

EDIN.  MED.  JOUR.  XXXIII.,  II.  1061,  Use 
of  deep-buried  continuous  animal  suture  in 
perineorrhaphy. 

AMER.  JOUR.  OBS.  1886.  710,  737,  Perineum 
as  a  supporting  structure,  some  of  the 
methods  of  perineorrhaphy  and  colpor- 
rhaphy.  1887.  532,  Method  of  perineor- 
rhaphy ;  1301,  1304,  Recent  (English)  methods 
of  perineorrhaphy. 


696 


APPENDIX. 


ARCHIV  F.  GYN.  XXVIII.  502,  Mekertts- 

chiantz  on  perineorrliaphy ;  492,  Perineo- 
plastic  operations,  Kiistner ;  493,  Complete 
perineoplastic  operation,  Korn.  XXXI. 

450,  New  (English)  methods  of  perineorrliaphy, 
Siinger.  XxyiT.  463t  Perineo-plastic  opera- 
tions, Zweifel.  XXXIII.  308,  Perineor- 
rhaphy  with  Lawson  Tait. 

CENTRALB.  F.  GYN.  X.  49,  Perineo-plastic 

operation,  Lanenstein  ;  392,  Local  anaesthesia 
in  operation.  XI.  473,  Perineoplastic  opera- 
tion, Fritech.  XII.  765,  Perineorrhaphy, 

ZEITSCH.'  F.  GEB.  UND  GYN.  XIII.  98, 

Perineoplastic  operations,  Kustner.          XIV. 

82,  Development  of  and  relation  to  certain 

malformations. 
YOLK.  SAMML.          No.  301,  Perineorrhaphy  by 

splitting  septum  and  making  flaps,  Siinger. 
ANNAL.  DI  OSTET.  1886.  259,  397,  Repair 

of,  Morisani. 

PERITONEUM  AND  CELLULAR  TISSUE, 
AFFECTIONS  OF. 

BRIT.  MED.  JOUR.  1887, 1.  782,  Methods  of 
cleansing. 

LANCET.  1886,  1. 110,  Milky  fluid  in  peri- 

toneal cavity. 

AMER.  JOUR.  OBS.  1886.  265,  Involved  in 

tuberculosis  of  the  uterus ;  !>64,  Intra-  or 
post-  peritoneal  abscess.  1887.  Vaginal 

pressure  in  treatment  of  chronic  pelvic  disease; 
932,  Laparotoniy  for  tuberculosis,  Van  de 
Warker ;  957,  Intra  -  peritoneal  adhesions. 
1888.  414,  Intra-ligamentary  cysts  ;  513,  Cal- 
cified cyst,  pelvic ;  1114,  Relaxation  of  peri- 
toneum. 

ARCHIV  F.  GYN.  XXXI.  373,  Pseudo- 

myxoma ;  4(54,  Laparotoniy  for  tuberculosis. 

CENTRALB.  F.  GYN.  X.  447,  Connective 

tissue  in  the  pelvis  and  its  pathology.  XII. 
775,  Treatment  of  intestinal  affections  from 
peritoneal  adhesions. 

PERITONEUM  AND  CELLULAR  TISSUE, 
INFLAMMATION  OF. 

BRIT.  MED.  JOUR.  1886,  I.  458,  Abscess  of 
Liver  following  pelvic  cellulitis ;  522,  Pelvic 
peritonitis ;  1065,  Serous  perimetritis,  or 
peritonitis.  1886,  II.  1212,  Acute  peri- 

tonitis. 1887,  II.  93,  Gonorrhoeal  peri- 

tonitis ;  1061,  Laparotomy  for ;  1094,  Elec- 
tricity for.  1888,  I.  1057,  Encysted  serous 
peritonitis.  1888,  II.  1395,  Encysted  serous 
peritonitis. 

LANCET.  1886,  I.  441,  Pelvic  abscess  ;  926, 

Serous  perimetritis.  1886,  II.  249,  Para- 

metric phlegmon  following  hydatid.  1887, 
I.  310,  Abdominal  section,  by  Mackay,  for 
pelvic  suppuration ;  409,  461,  Cases  of  peri- 
tonitis. 1888, 1.  268,  Two  cases  of  lapa- 
rotomy  for  tubercular  peritonitis,  by  Homans; 
719,  Abdominal  section  for  peritonitis,  by 
Smith  and  Burford.  1888,  II.  1021, 
Suppurative  peritonitis ;  1170,  Tubercular 
peritonitis  laparotomy  for,  by  Mayo 
Robson. 

EDIN.  MED.  JOUR.  XXXIIL,  II.  600,  Peri- 
tonitis ante-partum.  XXXIV.,  I.  85, 
Vaginal  tampon  in  ;  564,  Cause  and  treatment 
of  pelvic  abscess. 

GLAS.  MED.  JOUR.  XXX.  92,  Vaginal  tam- 

pon in. 

AMER.  JOUR.  OBS.  1886,  65,  Secondary 

operation  for  acute  peritonitis,  by  Hunter ; 
102,  Posterior  parametritis  and  its  sequels ; 
104,  Minute  alterations  of  the  nerves  during 
parametric  atrophy;  155,  Sudden  obscure 
shock  during  chronic  pelvic  peritonitis;  189, 
Exaggerated  importance  of  minor  pelvic  in- 
flammations ;  390,  Myelitis  following  pelvic 
cellulitis  ;  742,  Pelvic  cellulitis ;  762,  Different 


kinds  of  cellulitis ;  838,  Ovaries  and  tubes 
from  case  of  pelvic  peritonitis;  122'.',  Elec- 
trolytic puncture  for  areolar  hyperplasia ; 
1252,  Observations  on.  1887.  60,  169, 

Stretching  of  old  intra-pelvic  adhesions  by 
pressure;  288,  Vaginal  tampon  in  adhesions; 
516,  Ibid. ;  548,  Antiseptic  tamponnement 
in;  1001,  Haemorrhngic  parametritis;  1092, 
Vaginal  tampon  in  ;  1290,  Adherent  intestines 
from  peritonitis  simulating  fibroid  tumour ; 
1297,  Salines  in  peritonitis  following  abdo- 
minal section.  1888.  408,  Laparotomy  for 
septic  peritonitis,  Boldt ;  447,  Surgical  treat- 
ment of  tubercular  peritonitis ;  498,  Septic 
peritonitis  and  death  following  dilatation  of  the 
cervix ;  499,  Septicperitonitisfollowinghystero- 
trachelorrhaphy  ;  006,  Death  from  peritonitis 
following  trachelorrhaphy  ;  (">07,  Ibid.,  follow- 
ing removal  of  a  cervical  fibroid  ;  713,  Cases 
of  abscess  opening  into  rectum  ;  916,  Remarks 
on  pelvic  peritonitis  and  year's  work  in  abdo- 
minal surgery,  Eastman;  1037,  Treatment  of 
pelvic  abscess ;  1070,  Contribution  to  study  of 
pelvic  abscess;  1074,  Treatment  of  suppura- 
tive  peritonitis  ;  1076,  Laparotomy  in  peri- 
tonitis; 1189,  Chronic  cellulitis ;  1275,  Chronic 
pelvic  peritonitis. 

CENTRALB.  F.  GYN.  X.  41,  Tubercular  peri- 
tonitis and  laparotomy,  Naumann ;  158, 
Tubercular  peritonitis ;  379,  The  usual  and 
non-infectious  peritonitis ;  619,  Peritonitis 
following  twisting  of  the  pedicle  in  ovario- 
tomy. XI.  33,  Tuberculosis;  72,  Peri- 
metritis ;  753,  Peritonitis  after  laparotomy ; 
822,  Laparotomy  in  tubercular  peritonitis, 
Schmalfuss.  XII.  367,  Tuberculosis;  505, 
Caesarean  section  in  septicaemia. 

VOLK.  SAMML.        No.  274,  Perimetritis'. 

ARCHIV.  DE  TOO.  1886.  752,  817,  Suppura- 
tive perimetritis,  surgical  interference,  Pozzi. 
1887.  625,  Perimetritis  and  aspiration. 

ANNAL.  DE  GYN.  XXVI.  IS,  Peritonitis 

with  sub-peritoneal  myoma  and  pregnancy. 
XXVII.  201,  Acute  metritis  and. 

ANNAL.  DI  OSTET.  1888.  354,  Treatment  of 
peri-uterine  adhesions ;  515,  Glycerine  plugs 
in  chronic  pelvic  inflammation. 

PERITONEUM    AND    CELLULAR    TISSUE, 

TUMOURS    OF.        (See    also    "  Abdominal 

Tumours.") 
LANCET.          1886,  II.   74,   Case  of  rupture  of 

pelvic   cyst.         1887,  I.   982,    Haemorrhagic 

parametiitip. 
EDIN.  MED.  JOUR.        XXXIV.,  I.  566,  Dangers 

of  galvano-puncture  in  ]>elvic  tumours. 
AMER.  JOUR.  OBS.         1886.  425,  Case  of  pelvic 

abscess  and  treatment ;   1227,  Pelvic  abscess. 

1887.  165,    Pelvic    abscess  complicated   with 
fibre-cyst    of    uterus ;    763,    Retro-peritoneal 
cysts    and    Mikulicz'a    system    of    drainage. 

1888.  1053,  Dangers  of  galvano-puncture  in. 
ANNAL.    DE    GYN.          XXIX.  97,     Peritoneal 

pelvic  fibrous. 

PERITONEUM  AND  CELLULAR  TISSUE- 
ILEMATOCELE  AND  HJEMATOMA. 

BRIT.  MED.  JOUR.  1886,  I.  339,  523,  Pelvic 
haematocele.  1886,  II-  691,  Ovaries  and 
tubes  in. 

LANCET.  1886, 1-  494,  Retro-uterine.  1886. 
II.  423,  Intraperitoneal  haematocele  ;  470,  S05, 
Lawson  Tait  on ;  604,  Subperitoneal ;  652, 
653,'  Letters  on.  1887,  I.  120,  Haema- 

tocele from  a  ruptured  Graafian  follicle  ;  496, 
Presence  of  blood  in  the  peritoneum.  1887, 
II.  762,  Haematocele. 

DUB.  MED.  JOUR.  LXXXV.  Ifi9,  Peri-uterine 
hrematocele.  LXXXVI.  203,  Peri-uterine 

hmmorrliage. 

AMER.  JOUR.  OBS.  1886.  82,  Two  cases  of 
pelvic  haematocele  ;  334,  Two  cases  of  extra- 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    697 


peritoneal  hiematoma  cured  by  vaginal  inci- 
sion and  drainage,  Munde  ;  448,  Peri-uterine 
hasmatocele  treated  by  negative  galvano-punc- 
ture  ;  1121,  Causation  and  treatment  of  pelvic 
hwmatocele  ;  1175,  Ibid.  1887.  103,  Cal- 
culus ;  1222,  Successful  operation  for  haema- 
tocele,  Phillips.  1888.  108,  Non-uterine 
hiematocele ;  027,  Large  suppurating  extra- 
peritoneal  hgematoma,  cured  by  laparotomy, 
Seymour;  1175,  Laparotouiy  v.  expectant 
treatment  in  haematocele. 

ARCHIV  F.  GYN.  XXIX.  389,  Peri-uterine 
hiematocele. 

CENTRALB.  F.  GVX.  X.  58,  Haematocele 
and  electricity ;  179,  Hwmatocele  processus 
vaginalis  peritonei.  XI.  329,  Haematoma 
of  round  ligament. 

PESSARIES 

BKIT.  MED.' JOUR.  1887,  I.  107,  Use  of  stem 
pessaries  ;  456,  624,  Use  and  abuse  of  ;  515, 
New  intra-uterine  stem  pessary  and  introducer; 
(578,  Modification  of  ring  ;  943,  Uterine  band 
with  pad  ;  1839,  Amenorrhcea  stem.  1887, 
II.  63,  Value  of  Hodge  ;  724,  New  galvanic 
stem  ;  836,  New  uterine  support  for  horse- 
women. 1888,  II.  129,  Hofman's  improved. 

LANCET.  1887,  I.  221,  New  flexible  glycerine 
ring.  1887,  II.  766,  New  uterine  support 
for  equestriennes. 

EDIN.  MED.  JOUR.  XXXI.,  II.  968,  Maclaren 
on.  XXXII.,  I.  173,  Indications  for,  and 
methods  of  use  ;  558,  Hewitt's  cradle  pessary. 
XXXIII.,  I.  128,  173,  Removal  of  encysted 
Wedgwood  "Ball  Pessary."  XXXIII.,  II. 
851,  Action  of  pessaries. 

GLAS.  MED.  JOUR.  XXVI.  76,  Meyer  on. 
XXVIII.  429,  History  of.  XXIX.  262, 

Action  of. 

AMER.  JOUR.  OBS.  1886.  000,  New  retrover- 
sion  stem  ;  750,  Encysted  ;  862,  Removed  in 
fourth  month  of  pregnancy.  1887. 50,  Stem 
worn  for  three  months  ;  845,  New  retroversion 
stem  ;  857,  For  procidentia  uteri.  1888. 
421,  New  uterine  elevator  ;  1105,  Schultze  on. 

ARCHIV  P.  GYN.  XXXIL  480,  A  few  notes 
on. 

CENTRALB.  F.  GYN.  X.  40,  Meyer  on.  XII. 
289,  Breisky's  ovarian. 

ARCHIV.  DE  TOC.  1886.  769,  Displacements 
of  the  uterus  and. 


RECTUM. 

BRIT.  MED.  JOUR.  1886,  II.  143,  Rectal 
fistula  and  haemorrhoids.  1887,  I.  447, 
Prolapse  of  upper  into  lower  part.  1887, 
II.  16,  Stricture  of  ;  25,  Rectal  alimentation  ; 
422,  Sigmoidostoniy ;  1320,  Case  of  cancer  of. 
1888,  I.  26,  Pascal" lodgments  ;  554,  Operation 
for  rectal  haemorrhage. 

LANCET.  1886,  I.  157,  Syphilitic  stricture  of. 
1886,  II.  262,  Operation  for  cancer,  by 
Gnarneri.  1887,  II.  655,  Cancer  of  ;  813, 
Villous  polypus  of.  1888,  I.  Rectal  concre- 
tion ;  876,  Chronic  obstruction  from  caries  of 
5th  lumlwr  vertebra  ;  1298.  Peculiar  case. 

GLAS.  MED.  JOUR.  XXVI.  457,  Excision  of 
cancer,  by  Napier. 

AMER.  JOUR.  OBS.  1888.  72,  Radical  cure  of 
rectocele  by  ligation. 


STERILITY. 

BRIT.  MED.  JOUR.  1888, 1.  844,  Treatment. 
1888,  II.  870,  And  obstructive  dysmenor- 
rhosi. 

LANCET.  1886,  I.  989,  Due  to  uterine  dis- 
placements. 1887,  I.  1073,  Clinical  notes 
on.  1887,  II.  403,  Notes  on.  1888,  I. 
87ti,  Rectal  concretion ;  1132,  Treatment  of 
and  obstructive  dysmenorrhcwi. 


EDIN.  MED.  JOUR.  XXXTV.,1.  566,  Import- 
ance of  microscope  in  treatment. 

GLAS.  MED.  JOUR.  XXIX.  366,  Clinical 
notes  on.  TCXY.  421,  Treatment  of  in 
dysmenorrhcea. 

DUB.  MED.  JOUR.  LXXXV.  297,  Treat- 

ment of  and  obstructive  dysmenorrhcea. 
LXXXVI.  73,  Discussion  on  preceding. 

AMER.  JOUR.  OBS.  1887.  623,  And  ante- 
flexion  with  disease  of  ovaries  ;  1094,  Causes 
and  treatment.  1888.  40,  78,  Electrolysis 
v.  rapid  dilatation  for  ;  111,  Ninety  cases  of 
one-child  sterility  ;  1055,  Importance  of  micro- 
scope in  treatment. 

CENTRALB.  F.  GYN.  XII.  287,  Ninety  cases 
of  one-child  sterility. 

SUPERINVOLUTION. 

AMER.  JOUR.  OBS.  1888.  1009,  Following 
trachelorrhaphy. 

SYPHILIS 

BRIT.  MED.  JOUR.  1886,  I.  55,  141,  239, 
Moot  points  in  ;  77,  Problems  of ;  132,  174, 
228,  Correspondence  on  moot  points.  1886, 
II.  1027,  Mercury  as  an  antidote.  1887, 

I.  132,  Diabetes  and  syphilis  ;  238,  Reproduc- 
tion of   syphilitic    virus ;    274,   Remarkable 
case  of  primary  8.  ;  416,  In  pregnancy  ;  569, 
Congenital,  with  multiple  joint  effusion  ;  583, 
Treatment ;    590,  Syphilitic    bydrocephalus  ; 
942,  Some  phases  of  cerebral ;  943,  Diagnosis 
and  treatment ;    982,  Nomenclature  of  skin 
diseases.         1887,  II.  1277,  Communicability 
through  the  saliva  ;  1303,  Myositis  syphilitica; 
1339,   Hereditary  in  adult;    1378,  Iodide  of 
potassium    for   gumma ;     1379,     Communic- 
ability through  the  saliva.         1888,  I.   44, 
Commnnicability  through    the  saliva ;    132, 
Small  doses  of  mercury  in  ;  151,  Unmerited  ; 
156,     Hysteria   and ;    279,    Communicability 
through  the  saliva;  321,  Calomel  injections 
in  ;  321,  Influence  of  erysipelas  on  ;  413,  417, 
Abortive  treatment  of  syphilis  ;  468,  Case  of  ; 
609,    Syphilitic    conjunctivitis;     665,    "The 
abortive  treatment   of   syphilis ; "    768,   823, 
Alleged  arrest  in  its  primary  stage ;  802,  Con- 
genital ;    905,    Injection    of    mercury ;    970, 
Malignant ;   971,  Orbital ;  980,  Rare  form  of 
congenital ;  1043,  Constitutional;  1277,  Modi- 
fying phthisis ;   1277,  Secondary,  in    an   old 
woman ;    1296,    Subcutaneous    injection    o£ 
"grey  oil."         1888,  II.  693,  Diagnosis  and 
treatment    of    syphilitic    affections    of    the 
nervous  system. 

LANCET.  1886, 1.  65,  157,  252,  Moot  points 
in ;  217,  Acquired  and  inherited ;  584,  633, 
Treatment;  680,  Bacillus  of;  692,  Neuralgia 
of ;  692,  Microscopic  section  of  papule ;  1038, 
Treatment.  1886,  II.  337,  Treatment ;  413, 
Effects  in  pregnancy  ;  462,  Hypodermic  treat- 
ment ;  621,  Acute  tonsilitis  in  tertiary. 
1887, 1.  22,  Syphiloma  of  heart ;  168,  Venereal 
diseases  in  girls  of  tender  age;  313,  "Indur- 
ation "  of  Hunterian  chancres  in  the  female  ; 
448,  Preventive  treatment;  473,  Methods  of 
administering  mercury  ;  780,  Syphilitic  coma ; 
828,  Case  of  hereditary;  943,  Carbolate  of 
mercury  in.  1887,  II.  T71,  Micro-organisms 
in  inherited ;  1015,  Lardaceous  disease  in  con- 
genital ;  1282,  Microbe  of.  1888,  I.  372, 
Abortive  treatment ;  426,  Case ;  422,  Case  of 
syphilitic  onychia  ;  826,  Intra-muscular  injec- 
tion of  mercury  in  ;  846,  Alanix-mercury  in  ; 
863,  And  its  treatment ;  937,  Micro-organisms 
of;  1017,  Practical  treatment  of.  1888, 

II.  82.  And  rickets. 

EDIN.  MED.  JOUR.  XXXI.,  II.  1091,  Na- 
tural History  and  Treatment;  1093^  Syphi- 
litic  ulceration  of  intestine.  XXXII. ,  I. 
92,  185,  280,  378,  Moot  points  in  natural 
history  of. 


698 


APPENDIX. 


EDIN.  MED.  JOUR.  XXXII.,  1 1.  004,  Spurious 
venereal  disease.  XXXIII.,  I.  9:i,  As  an 
etiologicnl  factor  in  disease.  XXXIII. ,  II. 
865,  Guiunia  in  the  trachea ;  807,  Ulcers  and 
their  relation  to  syphilis  ;  959,  Abortive  treat- 
ment. XXXIV.,  I.  79,  Earliest  symptoms 
of  inherited;  483,  Importance  and  eradica- 
tion. 

GLAS.  MED.  JOUR.  XXV.  87,  A  new  antisy- 
philitic.  XXVI.  230,  Conditions  increasing 
the  gravity  of ;  428,  Syphilitic  diseases  of 
upper  air  passages.  XXVII.,  I.  82,  Syphi- 
litic diseases  of  upper  air  passages  ;  219,  Syphi- 
litic affections  of  the  nervous  system. 

DUB.  MED.  JOUR.  LXXXII.  47ii,  Treatment 
of  syphilitic  condylomata.  LXXXV.  470, 
Ointment  for  syphilitic  rashes. 

CENTRALB.  F.  GYN.  X.  318,  Intra-uterine 
infection ;  403,  Reinfection  of  mother  through 
foetus ;  089,  In  pregnancy.  XII.  30,  And 
pregnancy. 

ARCH  IV.  DE  TOO.  1886.  913,  And  preg- 

nancy. 1887,  178,  Hereditary  syphilis  and 
subcutaneous  abscesses. 

ANNAL.  DI  OSTET.  1888.  503,  Treatment  of 
abortion  due  to. 


TAIT'S  OPERATION.  (Sec  also  "Fallopian  Tuba, 
Anatomy  itnd  A  fleet  ion*  of.") 

BRIT.  MED.  JOUR.  1886,  I.  880,  Specimens 
from  eleven  cases.  1886,  II.  852,  General 
principles  in  ;  10S2,  An  Address  on  by  Tait ; 
1101,  For  chronic  ovaritis  and  double  pyosal- 
pinx,  Edis.  1887,  I.  51,  On  removal  of  the 
uterine  appendages;  71,  117,  Report  on;  174, 
303,  339,  Correspondence  on  ;  450,  For  pyosal- 
pinx,  Tait ;  570,  Compared  with  normal  ovari- 
otomy and  Battey's  operation ;  1044,  By 
Bantock  ;  1104,  Specimens  from.  1887,  II. 
237,  By  Butler  Smythe,  for  constant  ovarian 
pain,  incessant  vomiting,  and  dysmenorrhoea. 
1888,  I.  249,  By  Granville  Bantock,  for  fibroid 
tumour  and  haemorrhage ;  358,  By  Tait,  for 
intense  hystero-epilepsy ;  908,  By  Granville 
Bantock  ;  13S7,  Influence  of  removal  of  uterus 
and  its  appendages  on  sexual  appetite ;  1394, 
By  Heywood  Smith. 

LANCET.  1887,  II.  1213,  By  Lawson  Tait,  for 
hystero-epilepsy. 

EDIN.  MED.  JOUR.  XXXI.,  II.  812,  Diseases 
and  removal  of  the  uterine  appendages. 
XXXIL,  I.  73,  By  Brewis;  207,  By  Halliday 
Croom ;  271,  By  Brewis ;  4ii8,  Removal  of  the 
uterine  appendages.  XXXIL,  II.  811,  839, 
883,  For  disease,  with  twenty-three  cases,  by 
Skene  Keith. 

AMER.  JOUR.  OBS.  1887.  180,  For  sub- 
involution  and  endometritis,  Kelly;  302, 
Three  successful  cases,  by  Wilson ;  702,  For 
fibro-myoma  of  uterus,  Jackson ;  779,  Two 
cases  by  Palmer;  1093,  By  Burton;  1277, 
Secondary  haemorrhage  following.  1888. 
158,  Five  cases  by  Dixon- Jones ;  337,  Removal 
of  uterine  appendages  and  small  ovarian 
tumours,  with  report  of  twelve  successful 
cases,  Byford ;  012,  Regular  menstruation 
after:  709,  By  Tnttle ;  939,  974,  Removal  of 
uterine  appendages  for  nymphomania  and 
uterine  myoma;  1200,  Specimen;  1209,  By 
Hall. 

ARCHIV  F.  GYN.  XXIX.  329,  Clinical 

observations  on. 

YOLK.  SAM  ML.  No.  323,  On  the  indications 
for.  No.  343,  Partial  removal  of  tubes  and 
ovaries. 

THERAPEUTICS. 

BRIT.  MED.  JOUR.  1886,  I.  274,  Strychnine 
in  uterine  hwmorrhage.  1887,  I.  339, 

Antifebrin ;  590,  Antifebrin  in  febrile  and 
non-febrile  diseases  ;  870,  Antifebrin  ;  1039, 


Hamamelis  virginica.  1887,  II.  '-:!7,  Salix 
nigra  as  a  sexual  sedative ;  520,  Boracic  acid 
in  leucorrhuia ;  1349,  Antipyrin  as  a  uterine 
sedative.  1888,  I.  19,  Oleateof  zinc  and 

iodoform  in  gynecology  ;  32,  Foreign  opinions 
of  antipyrin  ;  291,  Relations  of  gynecology  to 
general  therapeutics ;  1213,  1308,  Codeine  to 
relieve  pain  in  abdominal  disease. 

LANCET.  1887,  II.  004,  Therapeutical  value 

of  more  recent  additions  to  the  genito-urinary 
pharmacopoeia.  1888,  II.  1100,  Effect  of 

glycerine  on  the  quantity  of  secretion  poured 
into  the  vagina  ;  1238,  Action  of  certain  dmgs 
on  the  utero-ovarian  system. 

EDIN.  MED.  JOUR.  XXXI.,  II.  1104,  Physio- 
logical and  therapeutic  effects  of  water  ;it 
different  temperatures.  XXXIL,  I.  131, 

215,  Physiological  and  therapeutic  effects  of 
water  at  different  temperatures;  175,  Hydrastis 
canadensis  in  uterine  haemorrhages. 

DUB.  MED.  JOUR.  LXXXI.  471,  Antiphlo- 

gistic action  of  menthol.  LXXXVI.  457, 
527,  On  the  action  of  certain  drugs  on  the 
utero-ovarian  system. 

AMER.  JOUR.  OBS.  1886.  109,  Some  uses  of 
cocaine.  1887.  330,  Glycerine  tampon  as 
therapeutic  agent ;  1050,  Value  of  some  medi- 
cines in  haemorrhagic  conditions  of  uterus. 

CENTRALB.  F.  GYN.  X.  152,  Influence  of 

ergot  on  circulation  of  uterus ;  300,  Ergot 
preparations ;  309,  Action  of  cornutin  ;  528, 
Ergot  preparations  ;  025,  Kephir.  XI.  Ns, 
Glycerine  tampon  in  gynecology  ;  441,  Ergotin 
injection;  058,  Hydrastis  canadensis;  774, 
Painless  ergotin  injection.  XII.  3,  Ergotin ; 
114,  Ergotin  injection  ;  353,  Ibid. ;  434,  Glycer- 
ine per  rectum. 

ANNAL.    DI    OSTET.  1886.    50,    98,   209, 

Citrate  of  iron  hypodermically  in  anaemia. 
1887.  171,  Citrate  of  iron  hypodermically  in 
anaemia.  1888.  230,  Antipyrin  in  uterine 
colic. 


URETER. 

BRIT.  MED.  JOUR.          1887,  I.  1228,  Action  o 
the  ureters  in.          1888,  I.  1174,  Surgery  of 
1208,  Value  of  inspecting  orifices  of  by  electric 
light. 

LANCET.  1888,  I.   57,  K!3,   209,  425,  Some 

points  in  the  surgery  of  the  urinary  organs. 

EDIN.  MED.  JOUR.  XXXIV.,  I.  504,  Palpa- 
tion of. 

AMER.  JOUR.  OBS.  1886.  877,  Palpation  of. 
1887.  187,  Palpation  of ;  1294,  Palpation  and 
sounding  of.  1888.  318,  Catheterization  of 
the  ureters ;  1 032,  Palpation  of. 

ARCHIV  F.  GYN.  XXVIII.  54,  Palpation  of. 
XXIX.  2S9,  In  relation  to  vagina. 

CENTRALB.    F.    GYN.  X.  591,   Palpation. 

XL  297,  Function  in  recto- vesico- vaginal 
fistula  ;  384,  Palpation  of. 

ARCHIV.  DE  TOC.  1887.  185,  Fibrous  cervi- 
cal polypus  compressing. 

ANNAL.  DE  GYN.  XXIX.  408,  Yesico-utero- 
vaginal  fistula  and  gangrene  of  part  of. 

AMER.  JOUR.  OBS.  1888.  1035,  Cause  and 

treatment  of  urethrocele. 

ARCHIV  F.  GYN.        XXX.  89,  Ulceration. 

CENTRALB.  F.  GYN.  XI.  475,  Operation  on, 
Fritsch. 

UTERUS,  AFFECTIONS  OF  (UNCLASSED). 

BRIT.  MED.  JOUR.  1886,  I.  1170,  Pyometra. 
1886,  II.  000,  Diseases  treated  by  fluids  ;  090, 
Microscopic  sections  of  malignant  disease ; 
718,  Non-gravid  hydrorrhcea.  1887, 1. 112, 
Effect  of  tight-lacing  in  producing  flexions  of 
the  uterus ;  624,  Removal  of  soft  tumour, 
Heywood  Smith.  1887,  II.  00,  Uterine 

neuroses  ;  422,  The  endometrium  and  diseases 
of  the  uterine  appendages;  1349,  Hydrastis 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    699 


canadensis  in  uterine  haemorrhage.          1888, 

I.  972,  Ergot  in  subinvolntion  ;    1010,  Cyst 
connected   with   the  uterus    and    simulating 
enlargement  of  that  organ  ;  1274,  Electrolysis 
in  some  chronic  affections. 

LANCET.          1886,  I.  853,  Dilatation.         1886, 

II.  107,  Curette  in  diagnosis  and  treatment; 
4(30,     559,     Intra- uterine    gal vano  -  cautery. 
1887,   II.   218,  Abscess ;   964,    Hasmatometra 
with  degenerating  fibro-mycmia.  1888,  I. 
74,  Haemorrhage  of  rive  years'  standing  caused 
by  enlarged  and  cystic  ovary  :  OS1,  Suppurat- 
ing phlebitis  after  miscarriage  ;   944,   Unripe 
oranges   in   metrorrhagia  ;    079,   Cyst;    111(5, 
Alteration  of  uterine  mucosa  in  case  of  flbro- 
myoma.            1888,   II.  438,  Boracic  acid  in 
leucorrhoea. 

GLAS.  MED.  JOUR.  XXVI.  77,  Iodine  in 

catarrh.  XXVIII.  1,  On  haemorrhages  from 
the  unimpregnated  uterus  ;  70,  Hyster- 
orrhaphy.  XXIX.  305,  Boracic  ajkl  in 

treatment  of  leucorrhrea.  XXX.  421, 

Treatment  of  peri-uterine  phlegmasia  by  elec- 
tricity. 

DUB.  MED.  JOUR.  LXXXI.  4-J1,  Curette  in 
diagnosis  and  treatment.  LXXXIL  95, 

Antipyrin  as  a  uterine  haemostatic  ;  149,  418, 
Curette  in  diagnosis  and  treatment ;  202, 
Extract  of  hemlock  in  intra-uterine  inflani- 
mation  and  passive  haemorrhages.  LXXXIV. 
144,  Relation  to  affections  of  the  eye ;  152, 
Absce.ss  through  umbilicus.  LXXXV.  354, 
Haemorrhage  of  five  rears'  .standing. 

AMEK.  JOUR.  OBS.  '  1886.  69,  Malignant 
adenoma  ;  205,  Tuberculosis  involving  peri- 
toneum ;  1223,  Xew  method  of  treatment. 

1887.  103,  Calculus  ;  824,  Uterine  dyspepsia  ; 
1090,  Helation  between  changes  in  tissue  and 
changes    in    shape ;    1232,    Relation   between 
uterine  mucous  membrane  and  diseases  of  the 
adnexa.  1888.  63,  Myxo-fibroma  of  the 
endometrium ;  110,  Ulcerations  of;   218,  And 
cervical     lacerations  ;      257,      Ibid.   ;      1105, 
Adenoma. 

ARCHIV  F.  GYX.  XXXI.  376,  Paralysis  of 

womb  during  curetting.  XXXII.  487, 

Malign  and  simple  adenoma.  XXXIII.  317, 
Uterine  mucous  membrane  in  carcinoma  of 
the  vagina. 

CEXTRALB.  F.  GYX.  X.  116,  Xew  growths. 

XI.  757,  E  version  of  mucous  membrane 
through  interstitial  myoma.  XII.  87, 

Diagnosis  and  treatment  of  a  typical  uterine 
bleeding. 

ARCHIV.  DE.  TOC.  1886.  04,  And  digestive 

functions  ;  255,  Neuralgia.  1887.  644,  In 

morphinomania ;  721,  Scraping  of  uterus  in 
fungous  growths ;  893,  Fungosities  of  uterine 
mucous  membrane ;  9S5,  1025,  Hydatid  cysts 
of. 

AXXAL.  DE  GYX.  XXIX.  2''-5,  Uterine  seda- 
tive and  excitant.  XXX.  3,  Haemorrhage. 

UTERUS,  ANTEFLEXION  AND  ANTEVER- 
SION  OF. 

BRIT.  MED.  JOUR.  1886,  I.  264,  Xulliparous 
anteflexed  and  dilated  uterus  ;  927,  Cured  by 
pessary.  1887,  I.  1105,  Worst  cases  of 

flexions  ;  1278,  Treatment  of  obstinate  cases. 

1888,  I.  401,  Effect  of  flexion  on  patency  of 
uterine  canal.          1888,  II.   490,   In  case  of 
abortion  and  mole. 

EDIN.  MED.  JOUR.  XXXIV.,  I.  505, 

Etiology,  pathology,  and  treatment  of  ante- 
flexion. 

GLAS.  MED.  JOUR.  XXX.  419,  Electrolysis 
in  uterine  flexions. 

AMER.  JOUR.  OBS.  1886.  706,  Xew  mode  of 
treating  aggravated  anteversion.  1887. 
623,  Treatment  of  acquired  anteflexion  with 
disease  of  ovaries  and  sterility  ;  1058,  Intra- 
uterine  stem  in  flexions.  1888.  225,  Notes 


on  ;  397,  Ibid.  ;  1043,  Etiology,  pathology,  and 
treatment  of  anteflexions  of  the  uterus. 
ARCH  IV.  DE  TOC.        1887.  441,  During  labour ; 
1075,  Doleris  on  flexions. 

UTERUS,  CARCINOMA  OF. 

BRIT.  MELJ.  JOUR.  1886,  I.  437,  Clinical 
diagnosis  ;  432,  Diagnosis.  1886,  11.  788, 
Vulliet's  treatment ;  871,  Microscopic  speci- 
mens. 1887,  I.  5,  50,  100,  Lectures  on  ;  29, 
New  cure  for  ;  525,  Treatment  of,  by  hysterec- 
tomy ;  800,  Chlorate  of  potassium  in  epi 
t helioma  ;  1090,  Extirpation  for,  by  Stirling  ; 
1400,  Ibid.,  by  Fritsch.  1887,  II.  64,  Extir- 
pation for  cancer  of  cervix,  -by  Cotterell  ;  138, 
In  double  uterus  and  vagina  ;  929,  Cultiva- 
tion experiments  with  malignant  new  growths; 
1050,  Disease  simulating  epithelioma  ;  1157, 
Vaginal  hysterectomy  for  malignant  disease 
of  cervix,  Purcell.  1888,  I.  73,  Extirpa- 
tion for,  by  Ogston  ;  141,  Virchow  on  diagnosis 
and  prognosis  of  cancer  ;  280,  Parasitic  origin 
of  malignant  growths ;  761,  Recurrence  of 
malignant  growths  after  removal  ;  SCO,  Colloid 
cancer;  1011,  Extirpation  by  Lewers  for 
primary;  13S9,  Chian  turpentine  in.  1888, 
II.  151,  Carburetted  hydrogen  in  ;  505,  With 
fibroid  ;  1205,  Sir  Spencer  Wells  on. 

LAXCET.  1886,  I.  140,  Family  history  of 
cancer  patients ;  148,  Theory  of  cancerous 
inheritance  ;  309,  Statistics  ;  548,  Extirpation 
per  raginam,  by  hewers  ;  082,  825,  Excision, 
by  Jennings  ;  721,  Micro-organism  of  cancer  ; 
800,  Condition  of  blood-vessels  in.  1886, 
II.  720,  Cure  by  medical  treatment ;  719,  770, 
What  constitutes  malignancy ;  895,  Chian 
turpentine  in.  1887,  1.  0,  59,  100,  205,  301, 
358,  Harveian  lectures  on  ;  14,  Extirpation 
i»y  i-aginam,  by  Greig  Smith  ;  490,  Cancer  of 
the  body  ;  595,  Ibid.  ;  927,  1108,  Carbonate  of 
lime  in  arresting  growth.  1887,  II.  102, 
Two  cases  of  vaginal  extirpation  for,  by 
Braithwaite  ;  505,  Average  time  before  return 
of  cancerous  disease  after  amputation  ;  999, 
On  cancer  and  cancerous  diseases.  1888, 
I.  980,  Primary,  extirpation  of  uterus  for,  by 
Lewers;  12S7,  What  is  cancer?  1888,11. 
29,  Pathology  of  cancer ;  224,  Xovel  view  of 
the  nature  of  cancer  ;  1239.  J.  "Williams  on. 

EDIX.  MED.  JOUR.  XXXII.,  II.  658,  Pallia- 
tive treatment.  XXXIV.,  I.  87,  Diagnosis 
of  beginning  of  early  carcinoma  of  cervix  ; 
88,  Extirpation  for,  Fritsch ;  505,  High 
amputation  for  cancer. 

GLAS.  MED.  JOUR.  XXV.  249,  Pathology  of 
cancer;  271,  Pathology  and  etiology  of  cancer: 
329,  Importance  of  more  detailed  clinical 
study  of ;  342,  Pathology  of  cancer ;  354, 
Etiology  and  clinical  aspects  of ;  425,  Origin 
of  cancer ;  434,  Pathology  and  etiology  of 
cancer  ;  444,  Cancer  from  the  family  practi- 
tioner's point  of  view  ;  450,  First  indication 
of  cancer  and  the  precancerous  stage. 
XXVI.  1,  Cancer  in  some  of  its  clinical 
aspects ;  9,  Local  origin  of  cancer ;  17, 
Etiology  of  cancer  and  nature  of  rodent  ulcer; 
21,  Heredity  in  cancer ;  30,  34,  Close  of  dis- 
cussion on  cancer ;  39,  Pathology  and  clinical 
aspects ;  44,  Demonstration  illustrative  of 
cancer;  138,  Cancer  apparently  cured;  321, 
Kolpo-hystereetomy  fur,  with  tables  of  results. 
XXX.  181,  Immediate  and  remote  effects  of 
vaginal  hysterectomy  for  ;  422,  Diagnosis  of 
early  carcinoma  of  cervix. 

DUB.  MED.  JOUR.  LXXXIII.  285,  Diagnosis 
of  cancer  of  f  undns. 

AMKR.  JOUR.  OBS.  1886.  1S4,  Treatment; 
489,  With  sub- mucous  fibroid  ;  527,  Of  cervix: 
74!',  Epithelioma,  treated  by  mercuric  nitrate; 
1212,  Curability  of  cancer  through  operation  : 
1214,  Kolpo-bysterectomy  for.  1887.  107, 
Hysterectomy  for,  Koeberle  ;  220,  Extirpation 


700 


APPENDIX. 


for,  Schultze  ;  1095,  Modern  treatment;  110S, 
Extirpation  for,  Martin  ;  1150,  Recent  hys- 
terectomies for ;  1228,  Statistics  of  vaginal 
extirpation  for  ;  1230,  Of  cervix,  in  maiden 
of  nineteen  ;  1230,  Results  of  operation  for 
cancer  of  cervix.  1888.  68,  Of  uterus 

bilocularis  ;  90,  Of  cervix  ;  176,  Recent  hys- 
terectomies for  ;  400,  Amputation  of  cervix 
for,  consecutive  miscarriage  ;  437,  Columnar 
epithelioma  of  cervix  ;  443,  Chrobak  on  the 
treatment  of  ;  58-2,  Ford  Thompson  on  ;  635, 
Thompson  on  ;  725,  Post-mortem  specimens  ; 
782,  Malignant  adenoma  of  cervix ;  868, 
With  cirri i mid  cysts;  870,  Uterus  removed 
for,  Byford ;  8S4,  Vaginal  hysterectomy  for 
medullary,  Heed  ;  1045,  High  amputation  for, 
Reamy  ;  1112,  Operation  for  cervical,  Bauin- 
giirtner  ;  1114,  Condition  of  mucosa  of  uterus 
in  carcinoma  of  cervix. 

ARCHIV  F.  GYN.  XXIX.  359,  Sixty  total  ex- 
tirpations of  uterus  for ;  352,  Of  cervix. 
XXX.  401,  Extirpation  of  uterus  for,  Leopold; 
471,  Of  cervix  in  young  woman  of  nineteen. 
XXXII.  271,  Mucous  membrane  of  body  of 
uterus  in  cervical ;  501,  Operation  for  cervical, 
Baumgartner.  XXXIII.  14(5,  Changes  in 
the  endometrium  in  cervical. 

CENTRALB.  F.  GYN.  X.  92,  Cervical ;  127, 
Krysinsky  on  ;  171,  Tetanus  and  trismus  in  ; 
173,  Of  body ;  2tiO,  Total  extirpation  of, 
Schultze ;  534,  Origin  of  carcinoma  from 
chronic  inflammation  of  skin  and  mucous 
membrane ;  588,  Operation  for,  indications, 
Hofmeier;  589,  Cervical.  XI.  Ill,  180, 
Operation  and  statistics,  Martin  ;  227,  Total 
extirpation  for,  Sanger ;  514,  Total  extirpa- 
tion for,  statistics,  Martin.  XII.  71,  Latest 
views  on  treatment ;  209,  Hydrometra ;  213, 
Treatment  of  when  inoperable,  Schramm  ; 
487,  Application  of  zinc  chlor.  in  carcinoma 
of  portio  and  vagina ;  593,  Zinc  chlor.  in  ; 
755,  Endometritis  in. 

ZEITSCH.  F.  GEB.  UND  GYN.  XII.  Of 
mucous  membrane.  XIII.  S9,  Diagnosis  of 
commencing  ;  3(50,  Final  result  of  operation. 

VOLK.  SAMML.  No.  338,  Diagnosis  and  treat- 
ment of. 

ARCHIV.  DE  TOG.  1886.  204,  And  scraping  ; 
727,  Hysterectomy  for,  Koeberle. 

ANNAL.  DI  OSTET.        1888.  500,  Bromine  in. 

UTERUS,  DISPLACEMENTS  OF. 

BRIT.  MED.  JOUR.  1886,  II.  013,  Early 

history  and  etiology  of  flexions  ;  IKiO,  Flexions 
of  the  uterus.  1888,  I.  203,  Causes  and 
treatment ;  286,  Management  of  anterior  and 
posterior  displacements  ;  860,  Treatment  of. 

LANCET.        1886,  I.  537,  A  cause  of. 

AMER.  JOUR.  O1JS.  1887.  1040,  Causes  and 
treatment  of.  1888.  561,  And  electricity. 

ARCHIV  F.  GYN.  XXXI.  1,  Relation  of  nor- 
mal and  pathological  attachments  of  uterus  to. 

VOLK.  SAMML.  No.  332,  Stitching  replaced 
uterus  to  abdominal  wall. 

ARCHIV.  DE  TOO.     1886.  769,  And  pessaries. 

UTERUS,  ENDOMETRITIS  (For  TREATMENT, 
see  also  "Intro-uterine  Medication"). 

LANCET.        1887,  II.  117;  169,  Case. 

EDIN.  MED.  JOUR.  XXXIIL,  II.  8.14,  Curet- 
ting the  uterine  cavity.  XXXIV.,  I.  566, 
Treatment  of  chronic  by  drainage  with  gauze. 

GLAS.  MED.  JOUR.  XXVI.  460,  Treatment 
of.  XXVI.  68,  Ibid. 

DUB.  MED.  JOUR.  LXXXV.  348,  Treatment 
of. 

AMER.  JOUR.  OBSTET.  1886.  194,  Intra- 

uterine  treatment  of ;  352,  Ovarian  complica- 
tions of;  496.  K.  Funiionn.  with  amenorrhoaa. 
1887.  Ill,  Electrolysis  for;  559,  Chronic 
hyperplastic ;  897,  Fungous,  and  tumours 
of  mucosa  of  uterus;  1104,  Chronic;  1231, 


Veit  on.          1888.  1052,  Treatment  of  chronic 
by  drainage  with  gauze  ;  1067,  Treatment. 

ARCHIV    F.    GYN.  XXVIII.   163,    Chronic 

hyperplastic.          XXIX.  78,    "  Deciduome  ;  " 
346,  Of  body. 

CENTRALB.  F.  GYN.         X.  155,  B.  Fungosa  el 
poh/posa:    186,  Curetting;    1S7,  Ibid.        XL 
477,  Gonorrhoeal  vaginitis  and  ;  705,  In  preg- 
nancy ;  708,  Gonorrhoeal  vaginitis  and. 
XII.  134,  Heit/.mann  on  ;  241,  Non-puerperal  ;. 


XII.  134,  Heit/.mann  on  ;  241,  Non-puerperal  ; 
593,  Zinc,  chlor.  in  chronic  ;  755,  In  uterine 

XIII.  388, 


cancer. 
ZEITSCH.  F.  GEB.  UND  GYN. 

Endometritis. 
ARCHIV.   DE  TOG.         1886.  760,  Intra-uterine 

galvano-eautery   for.  1887.  17,  145,  193, 

314,  460,  Doleris  on. 
ANNAL.   DE  GYN.         XXIX.  401,  Cautery  and 

curetting  for. 

UTERUS,     EXTIRPATION     OF.       (See     also- 

"  Abdominal  Svri/try.") 

BRIT.  MED.  JOUR.'  1886,  I.  457,  for  cancer, 
by  Lewers ;  513,  for  cancer,  by  Stewart- 
Nairne ;  1065,  Removal  of  fundus,  Lawson 
Tait;  1216,  For  Myoma,  Aveling.  1886,. 
II.  78,  Vaginal,  by  Brennecke  ;  1 17,  Vaginal,  by 
Zaiaitsky.  1887,  I.  525,  For  cancer ;  583, 
Total,  by  Schmidt ;  678,  Vaginal,  by  Purcell ; 
1096,  Total  for  cancer,  by  Stirling;  1278, 
Supravaginal  for  fibroid,  Bantock  ;  1400,  Total 
forcancer,  by  Fritsch.  1887, 1 1. 64,  Forcancer 
of  cervix  ;  421,  And  pyelitis  ;  422,  Vaginal,  by 
Fritsch  ;  878,  By  Mayo  Robson  for  fibrocystia 
tumour  ;  1157,  Vaginal,  for  malignant  disease 
of  cervix,  Purcell;  1157,  Supravaginal,  Ban- 
tock ;  1257,  Keith's  results  of  supra  vaginal 
hysterectomy.  1888, 1.  73,  For  cancer,  by 
Ogston  ;  211,  Thirty-eight  cases,  by  C.  Braun, 
for  fibroids ;  740,  For  hystero-epilepsy,  by 
Imlach ;  757,  Abdomino-vaginal,  by  Reeves,  for 
fibroid  ;  798,  by  R.  T.  Smith,  after  electro- 
lysis for  fibroid  ;  1011,  by  Lewers,  for  primary 
carcinoma  of  body ;  1274,  By  Horrocks,  for 
inversion  ;  1386,  Supravaginal,  by  Granville 
Bantock,  for  multiple  fibroid  ;  1387,  Influence 
of  removal  of  uterus  and  its  appendages  on 
sexual  appetite.  1888,  II.  79,  Vaginal,  by 
Murphy,  for  Uterine  Fibroid ;  1113,  Supra- 
vaginal,  by  Meredith,  for  locked  fibroid. 

LANCET.  1886,  I.  416,  Vaginal,  by  Trelat,  for 
cancer.  1886,  II.  221,  With  Nephrectomy, 
by  Calderini.  1887,  I.  14,  Per  vaginam,  by 
Greig  Smith,  of  a  cancerous  and  pregnant 
uterus;  18,  Notes  on;  672,  By  Knowsley 
Thornton,  for  fibromyoma  in  patient  fifty-six 
years  of  age ;  820,  Extirpation  of  ruptured, 
by  Andrews ;  912,  Jennings  on.  1887,  II. 
162,  Two  cases  of  vaginal,  by  Braithwaite,  for 
carcinoma ;  238,  Vaginal ;  411,  Vaginal,  by 
Purcell,  for  malignant  disease;  811,  Supra- 
vaginal  hysterectomy  ;  964,  Supravaginal,  by 
Meredith,  for  hrematometra  associated  with 
a  degenerating  Fibromyoma.  1888,  I.  219, 
By  Oliver,  for  fibroid;  619,  Abdominal  for 
fibroid,  by  M'Mordie  ;  922,  973.  Three  cases 
by  Morris,  for  myomata  and  fibrocystic 
tumours;  980,  by  Lewers,  for  primary  cancer 
of  body.  1888,  II.  163,  By  Plinmier,  for 
cystic  myoma ;  210,  By  Macan  for  fibrous 
tumour. 

EDIN.  MED.  JOUR.  XXXIIL,  II.  S60,  Keith 
on  results  of  Supravaginal.  XXXIV.,  I.  88, 
By  Fritsch,  for  carcinoma ;  565,  Pressure 
forceps  vemi»  suture  and  ligature  in  vaginal. 

GLAS.  MED.  JOUR.  XXV.  228,  Suspension 
of  pedicle  after  vaginal.  XXVI.  321, 

Kolpo-hysterectomy  for  cancer  with  tables  of 
results.  XXX.  181,  Immediate  and  remote 
effects  of  vaginal  for  cancer. 

DUB.  MED.  JOUR.  LXXXV.  349,  Technique 
of  vaginal ;  526,  Case  of  vaginal,  in  which 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    701 


both    ureters    were    tied.          LXXXVL    63, 
Statistics  of  vaginal. 

AMER.  JOUR.  OBS.  1886.  69,  Supravaginal 
for  adenoma,  by  Wylie ;  81,  Supravaginal  for 
fibroid,  by  Montgomery;  137,  Hysterectomy 
versus  Oophorectomy  for  fibroid ;  199,  Total, 
per  cagi'iuim,  by  Battlelehner ;  204,  Of  corpm 
uteri,  by  Veit ;  205,  Vaginal,  Duevelius  ;  804, 
For  an  enormous  fibroid,  by  Atherton ;  824, 
Statistics  of  ;  836,  Vaginal,  by  Goodell ;  952, 
By  Wilson,  for  fibro-cystic ;  1136,  Five,  by 
Helnmth ;  1214,  Kolpo-hysterectomy  for 
cancer;  1298,  Per  vaglnam,  by  Brennecke. 
1887.  75,  For  fibroids,  by  Parker ;  107,  For 
cancer,  Koeberle ;  108,  Technique  of  supra- 
vaginal  amputation ;  10S,  Suspension  of 
pedicle  after  supravaginal  amputation ;  184, 
For  myoma,  by  Price ;  220,  For  cancer, 
Schultze ;  520,  Two  cases  of  vaginal,  by 
Munde ;  851,  For  fibroids,  by  Freeman  ;  879, 
For  soft  myo-fibroma,  Parkes ;  1008,  Sixty 
vaginal,  Fritsch ;  1055,  Pedicle  in  supra- 
vaginal  ;  1108,  Vaginal  for  cancer,  by  Martin  ; 
1145,  Technique  of  vaginal ;  1150,  Recent, 
for  cancer  ;  1184,  For  fibrous  tumour,  Hanks  ; 
1186,  For  epithelioma,  by  Munde ;  1207,  For 
cancer,  Weston  ;  1228,  Statistics  of  vaginal  for 
cancer ;  1228,  Thirty-eight  hystero-myomo- 
tomies,  by  Braun ;  1229,  Forty-eight  total, 
Leopold.  1888.  81,  Three  cases  of  vaginal, 
Etheridge ;  108,  Extra-peritoneal ;  176, 
Recent,  for  cancer ;  177,  Vaginal,  for  great 
hypertrophy  of  cervix,  Hunter  ;  178,  Laparo- 
hysterectomy,  Byrne ;  303,  For  fibroid, 
Munde ;  424,  Vaginal,  for  sarcoma,  Dudley ; 
427,  Case  of  vaginal,  Byford ;  604,  Combined 
vaginal  and  abdominal,  for  myoma,  Dixon 
Jones;  609,  Vaginal,  Hunter;  627,  In  last 
months  of  pregnancy,  Hamill ;  642,  743,  Per 
vaginam,  for  nbro-sarcoma  and  for  carcinoma, 
Byford;  870,  For  carcinoma,  Byford;  884, 
Vaginal,  for  medullary  cancer,  Reed ;  945, 
With  ovariotomy  and  abdominal  section, 
Baldy ;  1048,  Pressure  forceps  versus  the 
suture  and  the  ligature  in  Vaginal ;  1185, 
Vaginal  for  procidentia  with  epithelioma  of 
cervix  and  vagina ;  1230,  Ileus  following 
vaginal ;  1270,  Supra-pubic  for  fibroid, 
Dudley. 

ARCHIV  F.  GYN.  XXIX.  359,  Sixty  cases  for 
cancer,  Fritsch.  Jfx"g  1,  Extraperitoneal, 
Frank  ;  132,  Account  of  hystero-myomotomy, 
Lebedeff ;  401,  Forty-eight  cases,  for  cancer, 
Prolapse  and  neuroses,  Leopold.  XXXIII. 
317,  Vaginal,  for  cancer  of  vagina,  Thieni ; 
320,  Extra-peritoneal  vaginal,  Frank. 
CENTRALB.  F.  GYN.  X.  30,  Total,  Leopold  ; 
32,  40,  Supravaginal  and  oophorectomy  for 
Fibro-myoma ;  260,  Total  for  cancer,  Schultze ; 
805,  Amputation  for  myoma,  Gusserow. 
XI.  150,  Freund's  operation,  Sanger ;  185, 
Vaginal,  Mttller ;  227,  Total,  for  cancer, 
Sanger ;  425,  Vaginal  total,  with  ovariotomy, 
Asch  ;  435,  Supravaginal  amputation  of  preg- 
nant uterus  for  myoma,  Vogel ;  514,  Total 
for  carcinoma,  statistics,  Martin.  XII.  409, 
Copenhagen  statistics  of  vaginal  total ;  817, 
Per  vayinam,  modification,  Stratz. 
ZEITSCH.  F.  GEB.  UNO  GYN.  XII.  56. 

Vaginal  total,  Brennecke. 
VOLK.     SAMML.          No.    339,    Sixty    cases    of 

laparo-myomotomy,  Fritsch. 

ARCHIV.  DE  TOO.  1886.  28,  Ovario-hysterec- 
tomy,  Terrier;  30,  Vaginal,  Gillete ;  107, 
Abdominal  and  vaginal,  and  amputation  of 
cervix,  Clado ;  727,  For  cancer,  Koeberle ; 
889,  Bifid  uterus  and,  Doleris ;  891,  Hsemo- 
stasis  in  vaginal ;  1021,  Vaginal,  Pean. 

1887.  364,    Vaginal    for    sarcoma,    Doleris. 

1888.  59t>,  Results  of  vaginal. 

ANNAL.  DE  GYN.  XXIX.  341,  Abdominal, 
Terrillon.  XXX.  87, 179,  Vaginal  for  cancer. 


ANNAL.  DI  OSTET.  1886.  138,  149,  Supra- 
vaginal,  for  fibroids,  Negri  ;  142,  Supravaginal 
for  fibro-cystic  tumour,  Negri.  1888.  24, 
Supra-vaginal  amputation  for  fibroid,  Fasola  ; 
466,  Supra- vaginal  for  fibroid,  Cosantini. 

UTERUS,  FIBRO-CYSTIC  TUMOURS  OF. 

BRIT.  MED.  JOUR.  1886,  I.  1169,  Cystic 
myoma.  1888, 1048,  Nature  of. 

LANCET.  1888,  I.  973,  Case  of  hysterectomy 
for,  by  Morris.  1888,  II.  163,  Hysterec- 
tomy by  Plimmer  for. 

AMER.  JOUR.  OBS.  1886. 952,  Hysterectomy 
for,  by  Wilson;  1090,  Case.  1887.  32, 
Interstitial;  165,  With  pelvic  abscess;  734, 
Laparotomy  for.  1888.  512,  Case;  942, 
Case ;  1200,  Fibro-cysto-sarcoma. 

ARCHIV  F.  GYN.  XXX.  249,  Diagnosis  of 
cystic. 

CENTRALB.  F.  GYN.  XI.  361,  Vaginal  ex- 
tirpation of  an  intra-mural,  Swiecicki. 

ARCHIV.  DE  TOC.  1887.430,  Case;  860, 
Ibid. 

ANNAL.  DI  OSTET.  1886.  13,  Case  of;  142, 
Supravaginal  amputation  for. 

UTERUS,  FIBROID  OF. 

BRIT.  MED.  JOUR.  1886, 1.  441,  586,  Com- 
plicating pregnancy ;  486,  Surgical  treatment 
of ;  821,  Diagnosis  between  distension  of 
tubes  and ;  980,  Specimens ;  1074,  Speci- 
men. 1886,  11.  78,  Specimen  of  slough- 
ing; 356,  Large  fibroid  in  inversion  of 
uterus ;  474,  Differential  diagnosis  from  preg- 
nancy ;  871,  Microscopic  sections  of  epithelium 
of ;  978,  Enucleated  per  vaginam,  Bantock ; 
97S,  Removed  for  growth  and  menorrhagia, 
Heywood  Smith.  1887,  (I.  678,  Removed 
by  abdominal  operation,  Meadows  ;  799,  Para- 
sites in;  1017,  Electrolysis  for;  1208,  Electri- 
city for  ;  1329,  Electricity  for ;  1364,  Electro- 
lysis for.  1887,  II.  02,  Electricity  for;  116, 
Ibid.;  423,  Ibid.;  699,  Ibid.;  702,  Ibid.;  724, 
Electrolysis  for;  878,  Hysterectomy  for,  by 
Mayo  Robson  ;  964,  965,  Apostoli's  treatment ; 
993,  Electrolysis  for,  followed  by  enucleation 
and  sloughing  ;  1020,  Electricity  for  ;  1075, 
1076,  Ibid.;  1257,  Keith's  results  in  treatment 
of.  1888, 1. 20,  Electrolysis  for  ;  102,  Ibid. ; 
160,  Ibid.;  211,  Thirty-eight  extirpations  of 
uterus  by  C.  Braun  for  ;  249,  Tail's  operation 
for;  439,  Electrical  treatment  of;  493,  Ibid.; 
538,  Oophorectomy  by  Lunn  for ;  538,  Elec- 
tricity for ;  547,  Treatment  of ;  614,  Electro- 
lysis for;  665,  Ibid.;  756,  799,  Extirpation 
for,  by  Reeves ;  798,  Hysterectomy,  by  R.  T. 
Smith,  after  electrolysis  for ;  799,  Action  of 
constant  current  on ;  861,  Enormous  myoma  ; 
997,  Electrolysis  for;  1065,  Electricity  for 
myomata  ;  1300,  Electricity  for  ;  1362,  Apos- 
toli's treatment  of;  1376,  Ibid.,  Notes  on 
three  cases  ;  138(5,  Supravaginal  hysterectomy 
for,  by  Granville  Bantock  ;  1386,  Ibid,  and 
oophorectomy  for,  Edis.  1888,  II.  77, 

Oophorectomy  by  Lunn,  for  bleeding  fibroid ; 
79,  Hysterectomy  for,  by  Murphy;  79,  Elec- 
tricity for;  102,  ApostoJi's  treatment  of ;  123, 
Treatment  of  haemorrhage  from,  by  hydrastis 
canadensis ;  505,  With  cancer ;  940,  With  ab- 
scess of  ovary  ;  1112,  Myoma  and  fibromyoma, 
and  allied  tumours  of  ovary;  1113,  Supra- 
vaginal  hysterectomy  for  locked  fibroid,  by 
Meredith  ;  1183,  Remarkable  case  of ;  1336, 
Abdominal  section,  by  M'Mordie,  for  large 
fibroid ;  1412,  Electrolysis  for. 

LANCET.  1886,  I.  62,  Three  cases  ;  297,  Spon- 
taneous expulsion  ;  833,  Colloid  degeneration 
in ;  1222,  In  twin  pregnancy.  1886,  II. 
211,  Medical  and  surgical  treatment;  811, 
859,  Treatment  of  fibro-myoma.  1887,  I. 
189,  Elastic  ligature  for;  672,  Hysterectomy 
for,  by  Knowsley  Thornton.  1887,  II.  127, 


702 


APPENDIX. 


Treatment  by  electricity  ;  324,  Ibid.         1888, 

I.  21!»,   Hysterectomy   for,    by  Oliver;    21!', 
With  labour  at  term  ;  370,  Electrolysis  for;  619, 
Abdominal  hysterectomy  for,  by   M'Mordie; 
(574,  Bleeding  fibroid,  oophorectomy  by  Lunn  ; 
674,     Electricity    for ;     919,    Caeaarean    sec- 
tion for  impauteil  fibroid  ;    124!),  Electricity 
for  myomata ;   1888,  II.  IS,  Enucleation  of 
three,  by  D.  MacGregor ;   210,    Removal  per 
vayinam,  by  Byrne ;   90S),  Myoma  and  fibro- 
myoma,   and  allied  tumours  of  the  ovary ; 
!>6t),  Locked ;  1058,  Myoma. 

EDIN.  MED.  JOUR.  XXXI.,  II.  764,  Re- 
moved at  III. -Stage  by  Halliday  Croom ; 
1176,  Treatment  of  fibro-myomata  by  lapar- 
otomy.  XXXIII.,  I.  270,  Case  ;  470,  Patient 
treated  by  Apostoli's  method.  XXXIII., 

II.  670,  088,  Electricity  for ;  860,  Keith  on  old 
and  new  ways  of  treating ;  1057,  Curette  in 
haemorrhage  from. 

GLAS.  MED.  JOUR.  XXIX.,  82,  Electricity 
for. 

DUB.  MED.  JOUR.  LXXXIII.  2S3,  Report 
on  mucous  membrane  in  cases  of  myoma ; 
476,  Case.  LXXXVI.  72,  Removal  of  large, 
by  M'Mordie;  202,  Specimen  with  uterus; 
252,  Removed  per  i-ayiiunn,  by  Byrne. 

AMER.  JOUR.  OBS.  1886.  44,  Sessile  fibroids, 
removed  by  Kelly ;  49,  Complicating  labour  ; 
167,  Bleeding,  oophorectomy  by  Goodell ;  204, 
Myoma  weighing  30  Ibs. ;  293,  Small  cal- 
careous degeneration ;  468,  Amputation  for 
Myoma,  by  A.  Martin ;  468  Myoma  with  sal- 
pingitis ;  483,  Oophorectomy  for ;  489,  Sub- 
muoous,  with  cancer  of  cervix  and  body  ;  604, 
Spontaneous  extrusion :  613,  Hegar's  opera- 
tion for  sessile  sub-mucous,  Lee ;  804,  Hyste>- 
rectomy  by  Atherton  for  an  enormous  ;  813, 
859,  Etiology  ;  976,  Treated  by  fluid  extract  of 
ergot ;  1112,  Clinical  initial  stage  of  myoma ; 
1172,  Oophorectomy  for,  by  Price.  1887. 
55,  Intra-uterine  in  a  virgin,  removed  by 
Munde  ;  69,  Multilocular ;  113,  Galvanic  treat- 
ment ;  253,  376,  Electricity  for,  fifty  cases ; 
290,  Electrolysis  for  ;  783,  Uterine  mucosa  in 
myomata;  851,  Hysterectomy  for ;  961,  Spon- 
taneous expulsion  of;  1102,  New  method  of 
electricity  for;  1106,  Marriage  and  nbroid; 
1112,  Surgical  treatment;  1112,  Ergot  for 
myoma;  1184,  Hysterectomy  for,  Hanks; 
1228,  Thirty  -  eight  hystero  -  myomotomies. 
Braun  ;  1286,  Removal  by  abdominal  section, 
Bantock.  1888.  62,  Weighing  140  Ibs.;  156, 
Removal  of  large,  by  laparotomy,  Ho  wans ; 
270,  Electricity  for  ;  303,  Hysterectomy  for, 
Munde  ;  321,  Intra-uterine  ;  335,  Wehmer  on  ; 
384,  Electricity  for  ;  442,  The  enucleation  of 
uterine  myomata,  Kleinwa^hter;  525,  With 
double  pyosalpinx  ;  557,  Comparative  thera- 
peutics of;  604,  Combined  abdominal  and 
vaginal  hysterectomy  for ;  615,  Submucous ; 
631,  Pelvic-bound  ;  643,  Galvanism  for,  fifteen 
cases ;  806,  Treated  by  Apostoli's  method  ; 
869,  Fibro-myomata ;  995,  Myomata ;  1092, 
Unusual  case  of  subserous;  1188,  Weighing 
18  Ibs.;  1205,  Subserous  fibre-myoma  of  the 
cervix  and  an  ovarian  cyst ;  1276,  Supra- 
pubic  hysterectomy  for.  Dudley. 

ARCHIV  F.  GYN.  XXVIII.  494,  Early  stages 
of  myoma ;  497,  Changes  in  uterine  mucous 
membrane  in  myoma.  XXIX.  1,  Mucous 
membrane  of  uterus  with  myoma ;  407,  Per- 
foration of  a  tubercular  ulcer  into  uterine 
cavity  with  myoma.  XXX.  132,  Account 
of  hystero-myomotomy,  Lebedeff.  XXXI. 

467,  Operation  for  subserous,  Baumgartner. 
XXXII.  470,  Myoma;  472,  Treatment  of 
pedicle  in  iiiyoinotomy,  Zweifel ;  473,  Myo- 
motomy.  XXXIII.  325,.  Intra-peritoneal 

treatment  of  stump  after  myomotomy, 
Schmidt;  449,  Operative  treatment  of  myoma, 
Friinkel. 


CEXTRALB.  F.  GYX.  X.  16,  Myoma;  40, 
Supra  -  vaginal  extirpation  of  uterus  and 
oophorectomy  for,  Vogelius ;  62,  Oophorec- 
tomy and  uterine  myoma,  Fraipont ;  123, 
Peptones  in  myoma  ;  168,  Myomotomy  ; 
257,  Oophorectomy  in  Fibro-myoma,  Gol- 
denberg ;  487,  Clinical  initial  stage  of  myo- 
mata ;  496,  Extirpation  by  laparotomy ; 
565,  Operative  treatment  of  myoma ;  649, 
Myoma  and  laparotomy,  Hager ;  805,  Ampu- 
tation for  myoma,  Gusserow.  XI.  97,  113, 
Myoma  operations  ;  245,  Myomotomy,  Sanger  ; 
345,  Ciesarean  section  for  myoma,  Klotz ; 
391,  Myomotomy  in  pregnancy,  Frommel ; 

435,  Supravaginal  amputation  for,   in  preg- 
nancy, Vogel  ;    489,   Removal  of  submucous, 
post-partum,  Urwitsch  ;  652,  Torsion  of  uterus 
in  myoma  ;  06S,  Treatment  of  myoma  during 
labour ;  757,  Eversion  of  uterine  mucous  mem- 
brane through  interstitial  myoma.        XII.  75, 
Myomotomy  by  special  method  ;  274,  Infarct  in 
the  parenchym  of  a  myoma;  713,  Myoma  by 
special  method ;    723,   In  pregnancy,  labour, 
and  puerperium  ;    729,   Bleeding  in   Myoma, 
801,  Myomotomy,  Freund ;  860,  Treatment  of 
pedicle  after  myomotomies. 

ZEITSCH.  F.   GEB.   UND  GYX.          XIV.  106, 

Myomotomy  and  Castration  in,  Wehmer  ;  223, 

Martin's  intraperitoneal  enucleation. 
VOLK.    SAMML.          No.    339.    Sixty    cases    of 

laparo-myomotomy,  Fritsch. 
ARCHIV.  DE  TOG.        1886.  633,  Myomotomy j>fj- 

ragincLM.          1887.  68,  Complicating  labour  ; 

573,  Ibid. 
AXXAL.  DE  GYN.        XXVI.  241,  Fibro-myoma 

in  cervix  of  girl  of  nineteen  years.          XXIX. 

416,  Battey's  operation  and,  Segond.        XXX. 

436,  Complicating  pregnancy  and  labour. 
AXNAL.  DI  OSTET.          1886.  98,  In  pregnancy 

with  dead  foetus  retained  ;  138,  149,  Supra- 
vaginal  extirpation  for,  Xegri ;  269,  Bilateral 
division  of  cervix  for,  Mancusi.  1887. 

155,  Oophorectomy  for;    171,   Pathology  of. 
1888.  1,  Oophorectomy  for,  Fascia  ;  24,  Supra- 
vaginal  amputation   for,    Fasola  ;    170,  Elec- 
tricity for  ;  440,  Supravaginal  for,  Cosantini ; 
492,  Expulsion  after  electricity  ;  493,  Enuclea- 
tion, Morisani. 

UTERUS,  INVERSION  OF. 

BRIT.  MED.  JOUR.  1886,  I.  475,  Lecture  on; 
491,  Immediately  following  labour  ;  641,  739, 
Cases  of.  1886,  II.  356,  With  large  fibroid. 

1887,  I.   66,  178,  Accidental  removal  of  an 
inverted  uterus ;    329,  508,  Complete  ;  1217, 
Case    of.  1888,    I.    1274,    Removal    by 
Horrocks.  1888,  II.  15,  Of  four  months' 
standing,  cure  by  Kempe. 

LANCET.  1886,  I.  420,  Treatment;   517, 

Question  of  priority  ;  613,  Treatment  of 
chronic.  1887,  I.  1281,  Two  cases  of  acute 
complete,  after  delivery ;  1293,  Hydrostatic 
pressure  in.  1887,  II.  49,  Letter  by  Hum- 
phreys on  ;  660,  With  complete  prolapse. 

1888,  II.  1276,  Case  of  complete. 

EDIN.  MED.  JOUR.  XXXIL,  II.  1041, 

Case  of  spontaneous.  XXXIII.,  1. 1,  Ibid. 

GLAS.  MED.  JOUR.  XXIX.  36,  Notes  on  a 

case  of  complete. 

AMER.  JOUR.  OBS.  1886.  604,  Partial, 

caused  by  spontaneous  extrusion  of  a  sub- 
mucous  fibroid.  1887.  130,  205,  Colpeurysis 
for,  Jaggard;  140,  Without  constitutional 
symptoms.  1888.  616,  Treatment ;  1116, 
Case  of ;  1279,  Laparotomy  for,  Munde. 

ARCHIV  F.  GYN.  XXIX.  321,  Kehrer  on. 

XXXII.  507,  Inversion  and  eversion  of  the 
uterus. 

CENTRALB.  F.  GYX.       X.  17,  Krukenbergon  ; 

156,  Kornon  ;  745,  Laparotomy  for.        XI.  17, 
Tearingout  of  in  verted  puerperal  uterus  in  1780; 
63,  Neugebauer  on.        XII.  401,  Teuffel  on. 


INDEX  OF  RECENT  GYNECOLOGICAL  LITERATURE.    703 


ARCHIV.  DE  TOC.  1886.  351,  Irreducible, 

and  amputation  by  elastic  ligature,  Poncet ; 
577,  Acute.  1887.   1042,   Operation   for, 

Faucon. 

UTERUS,  MALFORMATIONS  OF. 

BRIT.  MED.  JOUR.  1887,  II.  370,  Uterus 

septus  bicornis. 
LAXCET.  1887, 1.  487,  Pregnancy  in  an  im- 

perfectly  canalised  uterine  cornu. 
EDIX.  MED.  JOUR.        XXXII.,  II.  734,  Case  of 

absence  of  uterus  and  vagina. 
GLAS.  MED.  JOUR.        XXVI.  ISO,  Double. 
AMER.  JOUR.  OBS.        1887. 168,  Double  ;  660, 

Bicorporalis  ;  1063,  Infantile.  1888.  68, 

Bilocularis,  carcinoma  of;    1231,  Malforma- 
tion of  female  genitals. 
ARCHIV  F.  GYX.        XXXIIL  312,  Woman  with 

rudimentary  sexual  organs. 
CEXTRALB.  F.  GYX.  XI.  377,  Absence  of, 

with  normal  vagina ;   493,    Ibid ;    070,  Ibid. 

XII.  49,  Absence  of,  and  normal  vagina ;  236, 

Didelphys  ;  474,  Rudimentary  and  obliterated 

vagina. 
ZEITSCH.  F.  GEB.  UXD  GYX.  XIV.  140,  j 

Las  Casas  Dos  Santos  on  ;  369,  Anomalies  of. 
ARCHIV.  DE  TOC.  1886.  889,  Bifid,  and  j 

Hysterectomy,  Doleris. 

UTERUS,  METRITIS  OF. 

LAXCET.  1886, 1.  125,  In  young  girls,  treat- 
ment. 

EDIX.  MED.  JOUR.  XXXIL,  I.  176,  Treat- 
ment of  chronic. 

GLAS.  MED.  JOUR.  XXV.  75,  Subinvolution 
and  chronic  metritis. 

AMER.  JOUR.  OBS.  1887.  Ill,  Electrolysis 
for  ;  969,  Treatment  of  chronic. 

ARCHIV.  DE  TOC.  1886.  760,  Intra-uterine 
galvano-cautery  for. 

AXXAL.  DE  GYN.  XXVII.  201,  Acute,  and 
peritonitis. 

UTERUS,  POLYPUS  OF. 

BRIT.    MED.    JOUR.         1886,  I.   16,   Peculiar 

form  of.        1888,  II.  1283,  Sloughing  fibrous ; 

1395,  Fibroid,  removed  by  torsion. 
LANCET.        1886,  I.  20,  Fibro-myomatous ;  20, 

Ibid.        1886,  II.  167,  Case  of ;  976,  Sections 

of.        1888,  II.  1281,  Sloughing  fibrous. 
EDIN.      MED.     JOUR.  XXXIL,   I.    268, 

289,      Fibrous,      complicating     puerperium. 

XXXIII.,  I.  77,  Pediculated. 
GLAS.  MED.  JOUR.        XXV.  300,  Removed  with 

galvanic  ecraseur,   by  Reid.         XXIX.  150, 

Removal  from  os  uteri. 

DUB.     MED.     JOUR.          LXXXI.   165.    Fibro- 
myomatous.         LXXXII.  418,  Case. 
AMER.    JOUR.    OBS.          1886.    833,    Fibroid; 

1283,  Ibid. 
ARCHIV.   DE  TOC.        1887.  125,  189,  Fibrous 

cervical  polypus  compressing  ureters.       1888. 

739,  And  electricity. 
AXXAL.  DI  OSTET.        1886.  56,  Lipomatous. 

UTERUS,  POSITION  OF. 

ARCHIV  F.  GYX.        XXIX.  342,  Stratz  on. 

CENTRALB.  F.  GYX.  X.  495,  505,  Changes 
in,  and  treatment.  XI.  2tiO,  Position  of  the 
internal  genitals  of  nulliparae ;  743,  Patho- 
logical adhesions  of  uterus  and  malpositions. 
XII.  205,  Peritoneal  adhesions  in  malposi- 
tions. 

UTERUS,  RETROFLEXION  AND  RETRO- 
VERSION  OF. 

BRIT.  MED.  JOUR.  1887,  I.  526,  Hystero- 
rrhaphy; 1165,  Worst  cases  of  flexions  ;  1278, 
Treatment  of  obstinate  cases.  1887,  II. 
239,  A  cause  of  retroflexion.  1888,  I.  461, 
Effect  of  flexion  on  patency  of  uterine  canal. 

LAXCET.        1887,  II.  14,  Retrovereion  in  virgin. 


EDIX.  MED.  JOUR.        XXXIL,  I.  172,  Etiology 

GLAS'.  MED.  JOUR.  XXVII.  418,  On  Retro 
flexion.  XXX.  181,  New  operation  for  fixed 
retroflexion ;  419,  Electrolysis  in  uterine 
flexions. 

DUB.  MED.  JOUR.  LXXXIIL  286,  Report  on 
mechanical  treatment  of  backward  displace- 
ments. LXXXV.  351,  Treatment  of  retro- 
flexion  with  adhesions. 

AMER.  JOUR.  OBS.  1886.  188,  Causes  of 
retroflexion.  1887.  33,  Hysterorrhaphy  ; 
67,  Hysterorrhaphy  ;  146,  Retroversio-flexio  ; 
448,  Retroflexio  uteri ;  (530,  Laparotomy  for 
adherent,  Polk  ;  1028,  Knee-chest  posture  and 
replacement;  1058,  Intra-uterine  stem  in 
flexions.  1888.  Ill,  Diagnosis  and  treat- 
ment of  adhesions  on  retroflexion  ;  225,  Notes 
on ;  397,  Ibid.  ;  401,  Hysterorrhaphy  for  re- 
troflexion with  fixation,  Coe  ;  558,  Operative 
treatment  of  retroflexion,  Ssenger ;  994,  Ab- 
dominal fixation  of  the  retroflexed  uterus ; 
994,  Ibid.  ;  997,  Therapeutics  of  retroflexed ; 
1118,  Cure  of  retroflexion  by  stitching  fundus 
to  abdominal  wall ;  1249,  Value  of  "  Hystero- 
rrhaphy "  in  retroflexion. 

ARCHIV  F.  GYN.  XXVIII.  228,  Vedeler  on 
Retroflexion.  XXIX.  316,  Mechanical  treat- 
ment. XXXIL  481,  Treatment  of  retro- 
flexion.  XXXIIL  313,  Vaginal  ligature  of 
uterus  in  retroflexion. 

CENTRALB.  F.  GYN.  X.  106,  Retroflexion; 
429,  New  operative  treatment  of  retroflexion, 
v.  Rabenau.  XI.  801,  Through  tumours. 
XII.  17,  34,  102,  Operative  treatment,  Siinger ; 
69,  Operative  treatment  of  retroflexion,  Klotz ; 
161,  Sewing  to  abdominal  wall  in  retroflexion, 
Leopold ;  181,  Operation  for  retroflexion, 
Schiicking;  211,  Operative  treatment  of 
retroflexion,  discussion  at  Dresden ;  732, 
Treatment  of,  Kaltenbach  ;  825,  Retroflexion 
with  adhesions,  manual  treatment,  Schultze. 

ZEITSCH.  F.  GEB.  UND  GYN.  XTV.  23, 
Retroflexion  and  adhesions. 

VOLK.  SAMML.  No.  332,  Stitching  replaced 
uterus  to  abdominal  wall. 

ARCHIV.  DE  TOC.  1887.  1075,  Doleris  on 
flexions. 

ANNAL.  DI  OSTET.  1888.  316,  Stitching  to 
abdominal  wall  for. 

UTERUS,  SARCOMA  OF. 

BRIT.  MED.  JOUR.  1886,  I.  548,  Extirpa- 

tion of  circumscribed  sarcoma  of  vagina  and 
uterus,  Lewers.  1888,  II.  1396,  Case  by 

Griffiths. 

LANCET.  1886,  I.  353,  Case.  1887,  II.  117, 
Specimen.  1888,  II.  1182,  Case. 

AMER.  JOUR.  OBS.  1886.  005,  Diffused, 

with  metastasis  of  liver  and  lungs.  1887. 
312,  Fibro-sarcoma ;  1196,  Rapid  development 
of  a  fibro-sarcoma.  1888.  201,  Fibro- 

sarcoma  ;  424,  Vaginal  hysterectomy  for, 
Dudley  ;  1200,  Fibro-cysto-sarcoma  ;  1289, 
Two  cases  of  alveolar. 

ARCHIV.  DE  TOC.  1887.  364,  Vaginal  extir- 
pation for,  Doleris. 

VAGINA,  AFFECTIONS  OF. 

BRIT.  MED.  JOUR.  1887,  Thrombus  in. 

1888,  II.  939,  Foreign  body  in. 

LANCET.  1886,  II.  694,  Tubercular  ulcera- 

tions;  864,  Diphtheria.  1887,  I.  1186, 

Diphtheritic  slough.  1887,  II.  117,  Fibroid 
of  anterior  wall ;  963,  Tumour.  1888,  I. 
935,  Complicated  case  of  occlusion  of  vagina. 
1888,  II.  166,  Operation  by  M'Mordie  for 
congenital  deficiency  of  recto- vaginal  septum  ; 
438,  Boracic  acid  in  leucorrhcea. 

EDIX.  MED.  JOUR.  XXXIIL,  I.  128,  173, 

Removal  of  encysted  ball  pessary. 


704 


APPENDIX. 


GLAS.  MED.  JOUR.  XXIX.  305,  Boracic 

acid  in  treatment  of  leucorrhnea. 

DUB.  MED.  JOUR.  LXXXTV.  56,  Double 

vaginal  orilice ;  415,  Congenital  absence  of 
ostium. 

AMER.  JOUR.  OBS.  1886.  802,  Two  cases  of 
occlusion  ;  1117,  Pathological  aftection  of 
mucosa;  1118,  Lacerations ;  1266,  Fibroma 
(fibre-sarcoma)  of  urethro-vaginal  septum. 

1887.  314,    Enterocele ;    430,   Emmet's    new 
operation  for  prolapse  of   posterior  vaginal 
wall ;  1189,  Absence,  with  history  of  a  case 
after  operation.  1888.    239,    Congenital 
absence  with   retention  of  menstrual  fluid  ; 
1272,  Foreign  body  from. 

ARCHIV  F.  GYN.  XXVIII.  497,  A  hitherto 

unknown  pathological  change  in  vaginal 
mucous  membrane  ;  500,  Rare  case  of  rupture; 
XXIX.  341,  Operation  in  congenital  deficiency, 
Hchlesinger. 

CENTRALB.     F.     GYN.  X.    572,    Duplex. 

XI.  70,   Tuberculosis ;    708,   In    prostitutes ; 
760,   Total  absence ;    817,   Foreign  bodies  in 
female  genitals.  XIL  474,  Obliterated, 
with  rudimentary  uterus ;    785,  Rupture  in 
coitus  ;     804,      Plastic     vaginal     operation, 
Fritsch. 

ZEIT3CH.  F.  GEB.  UND  GYN.  XIII.  135, 

Hmniatoma  of. 

ARCHIV.  DE  TOG.  1886.  135,  Congenital 

atresia ;  193,  234,  Cicatricial  contractions  of  ; 
337,  Chronic  vulvo-vaginal  glandular  inflam- 
mation. 

ANNAL.  DI  OSTET.  1886.  1,  Cancer.  1888. 
461,  Iltematometra  from  atresia  vaginae. 

VAGINA,  CARCINOMA  AND  SARCOMA  OF. 

BRIT.  MED.  JOUR.  1886,  I.  496,  Circum- 

scribed sarcoma.  1888,  I.  32,  Pregnancy 

after  removal  of  cancer  of  vagina.  1888,  II. 
626,  Sarcoma  in  children. 

LANCET.        1886,  II.  627,  Primary  carcinoma. 

ARCHIV  F.  GYN.        XXXII.  490,  Sarcoma. 

CENTRALB.   F.   GYN.          XI.  606,  Carcinoma. 

XII.  422,  Sarcoma  vaginas ;  487,  Application 
of  zinc  chlor.  in  carcinoma    of   portio  and 
vagina. 

AMER.  JOUR.  OBS.         1888. 1108,  Sarcoma  in 

childhood. 
ANNAL.  DI  OSTET.        1886.  1,  Carcinoma. 

VAGINA,  CYSTS  OF. 

AMER.  JOUR.  OBS.  1887.  415,  Of  anterior 
wall ;  1121,  Paper  on  ;  1241,  Paper  on  and 
literature  of. 

ARCHIV  F.  GYN.        XXXIII.  121,  Fischel  on. 

ARCHIV.  DE  TOC.  1886.  6,  Tillaux  on.  1887. 
539,  And  calculus. 

VAGINISMUS. 

BRIT.  MED.  JOUR.        1886,  II.  101,  Bantock  on. 

1888,  II.  720,  Cocaine  locally  in  ;  790,  Ibid. 
LANCET.        1887,  I.  527,  Treatment. 

•GLAS.  MED.  JOUR.        XXVIII.  398,  Treatment. 
DUB.    MED.    JOUR.         LXXXIII.  129,   Treat- 
ment ;  297,  Treatment. 


CENTRALB.    F.    GYN.          X.  96,   Droiahl  on; 

318,  Cocaine  in. 
ANNAL.  DE  GYN.        XXV.  245,  Guillet  on. 

VAGINITIS. 

DUB.  MED.  JOUR.       LXXXVI.  218,  Treatment, 

AMER.  JOUR.  OBS.  1886.  496,  Due  to  red 
ants  in  vagina.  1888.  1109,  Etiology  of 
vulvo-vaginitis  in  childhood. 

ARCHIV  F.  GYN.  XXXI.  363,  Emphysema- 
tous.  XXXII.  493,  Etiology  of  vulvo- 

vaginitis  in  childhood. 

CENTRALB.  F.  GYN.  XL  477,  Gonorrhoeal, 
and  Endometritis  ;  708,  Ibid.  XII.  422, 
Etiology  of  Vulvo-vaginitis  in  childhood. 

ANNAL.  DI  OSTET.  1887.  149, 178,  Emphyse- 
matous. 

VULVA,  AFFECTIONS  OF. 

BRIT.    MED.    JOUR.          1886,    I.    495,    Cyst. 

1887,  I.   1159,  Labial  thrombus.        1887,  II. 
898,  Large  tumour  of  labium  in  pregnancy. 

1888,  I.  22,  Pudendal  hsematocele ;  250,  Cysts 
from  the  labia  minora ;  545,  Primary  mela- 
nosis  of  ;  793,  Peppermint  water  in  pruritus  ; 
1349,  Tuberculous  ulceration  of.        1888,  II. 
75,  491,  Menthol  in  Pruritus;  915,  Treatment 
of  pruritus ;  1395,  Fibroma  of  nympha. 

LANCET.  1886,  I.  34,  Cause  of  pruritus. 
1886,  II.  108,  Labial  heematoma;  694,  Tuber- 
cular ulcerations ;  976,  Lupus  of.  1887, 1.  75, 
Large  thrombus  of  right  labiuin.  1887,  II. 
498,  Lupus  of ;  520,  Successful  treatment  of 
pruritus.  1888,  I.  74,  Pudendal  ha;matocele. 

EDIN.  MED.  JOUR.  XXXII.,  II.  657, 

Pruritus.  XXXIV.,  I.  172,  Bartholinian 

DUB.  MED.  JOUR.  LXXXII.  94,  Menthol  in 
urticaria  and  pruritus;  421,  Labial  liwnia- 
toma.  LXXXV.  356,  Pudendal  haematocele. 

AMER.  JOUR.  OBS.  1886,  895,  Cases  of 
Tumour.  1887.  167,  Sloughing  wound  of 
labium ;  785,  Lupus ;  Ig76,  Epithelioma. 
1888.  434,  Fibroid  of  the  vestibule;  1109, 
Etiology  of  vulvo-vaginitis  in  childhood ; 
1231,  Malformation  of  female  genitals. 

ARCHIV  F.  GYN.  XXXII.  400,  Melanotic 
tumour ;  493,  Etiology  of  vulvo-vaginitis  in 
childhood.  XXXIII.  115,  Chronic  ulcera- 

CENTRALB.  F.  GYN.  X.  235,  Carcinoma; 
305,  Literature  of  cancer  of.  XI.  70,  Tuber- 
culosis ;  454,  Cyst  of;  Ibid.,  Carcinoma;  521, 
Pruritus ;  639,  Cysts.  XII.  97,  Elephan- 
tiasis of  the  prsepuce  of  the  clitoris  and 
nymphae  ;  129,  Haematoma  of. 

ZEITSCH.  F.  GEB.  UND  GYN.  XIII.  135, 
Htematoma  of.  XTV.  199,  Lipoma  of 
labium. 

ARCHIV.  DE  TOC.  1886.  337,  Chronic  vulvo- 
vaginal  glandular  inflammation.  1887.  963, 
Perforation  of  labia  minora. 

ANNAL.  DE  GYN.  XXVI.  1,  General  mela- 
nosis  beginning  in  labia  minora.  XXX. 
17,  Persistence  of  "plaque  muqueuse"  in 
woman. 


IKDEX   OF  AUTHORS. 


ABBE,  671. 

Brown,  398. 

Dott,  150. 

Abel,  318,  465. 

Brown,  Baker,  242. 

Doueall.  148. 

Ackermami,  453. 

Bruckner,  536.                                    Drage,  313. 

Adams,  577. 

Brunton,  Lauder,  142,  145.               Drysdale,  222,  223,  446. 

Agnew,  212. 

Budin,  5,  28,  266.                                Duke,  270,  273. 

Albert,  431,  440. 

Bumm,  147,  670.                                Dull,  408. 

Alexander,  577. 

Byford,  441,  446,  619.                        Duncan,  John,  561. 

Allingham,  639. 

Byrne,  285,  395,  490,  491.                  Duncan,  Matthews,  5,  49,  116, 

Althaus,  427. 

171,  247,  206.  267.  268.  269. 

Ampere,  656.                                  |    CAMERON,  361.                                        313,  3S5J  394J  417J  464'  495J 

Apostoli,  341,427,428,652,653,         Campbell,  H.  F.,  374.                             544,  550,  554,  584,  588.  592. 

657,  658,  659,  660,  661. 

Cappie,  408.                                               593,  603. 

Aran,  577. 

Carrard,  4.                                          Duncan,  W.  626. 

Arnott,  H.  ,  480. 

Carron,  468.                                        Dunlap,  602. 

Ashford,  332. 

Chadwick,  37. 

Atle«,  234,  444. 

Championniere,  72. 

BADE,  408,  418. 

Atthill,  329,  395,  396. 

Champneys,  632. 

Eckart,  466. 

AveJing,  116,  398. 

Charcot,  666,  667. 

Eichwald,  222. 

Cheron,  533. 

Ellinger,  270. 

BABESIN,  445. 

Chiara,  247. 

Emmet,  106,  116,  120,  145,  176, 

Baer,  445,  452. 

Chiari,  275,  502. 

200,  267,  268,  272,  291,  292, 

Balfour,  74. 

Chisholm,  471  . 

293,  294,  295,  296,  297,  299, 

Ballantyne,  506. 

Chrobak,  266,  506. 

300,  301,  307,  336,  340,  346, 

Bandl,  42,  53,  194,  199,  350.          \     Cintrat,  436. 

394,  395,  398,  549,  553,  556, 

Bannon,  543.                                    !     Clarke,  453. 

607. 

Bantock,  Granville,  246,  346,        Claudius  51. 

Engelmann,   86,   88,  210,  211 

380,  382,  431,  440.                            Clay,  508,  510. 

061. 

Barbier,  537.                                      Clouston,  666. 

Englisch,  205. 

Barker,  277,  294,  471,  480,  569. 

Coats,  256. 

Eppinger,  482,  501. 

Barkow,  ;143. 

Cobbold,  188. 

Erich,  445. 

Barnes,  112,  114,  267,  285,  287, 

Coblenz,  215,  217,  226. 

Esmarck,  549. 

312,  329,  363,  389,  394,  396, 

Coghill,  271,  627. 

412,  453,  476,  480,  482,  485, 

Cohnstein,  330. 

FARRE,  23. 

491,  531. 

Collis,  561. 

Faucon,  393. 

Battey,  87,  109,  110,  202,  208, 

Conrad,  533. 

Felding,  441,  443. 

•209,  210,  211,  212,  329,  599. 

Coulomb,  656. 

Fenger,  445. 

Baumgartner,  431. 

Conrty,  394,  396,  401. 

Fere,  468. 

Bayle,  415. 

Crede,  182,  329,  388,  390,  520. 

Fergusson,  108,  111,  114,  134. 

Beates,  445. 

Groom,  347,  454. 

Fischel,  294,  304,  305,  583. 

Beck,  Snow,  336. 

Cross,  515. 

Foster,  7,  57,  66,  67. 

Bedson,  515. 

Crosse,  388,  389,  400. 

Fothergill,  Milner,  583. 

Beigel.  23,  86,  535. 

Cruveilhier,  51,  417. 

Foulerton,  329. 

Bell,  329. 

Cullinerworth,  223,  5:24. 

Foulis,  74,  100,  144,  158,  216, 

Bennet,  Hughes,  222,  223.                 Cunningham,  12. 

217,  2-22,  224,  225,  610. 

Bennet,  J.  Henry,  291,  323.              Cusco,  108,  112,  114,  ]34. 

Fox,  Wilson,  217. 

Berard,  620.                                        Cutter,  428. 

Frankel,  346,  304,  432,  494. 

Bernutz,  157,  160,  178. 

Czempin,  292,  301,  43-'. 

Frankenhauser,  73,  74. 

Berthold,  543. 

Czerny,  497,  649. 

Freund,  H.  W.,  170. 

Bird,  332. 

Freund,  W.  A.,  33,  47,  167,  174, 

Blackwood,  547. 

DALTON,  85,  88. 

175,  188,  212,  291,  387,  405, 

Blau,  467. 

Davaine,  149. 

411,  432,  494,  577,  664. 

Blundell,  208. 

Dawson,  446,  510. 

Friedreich,  545. 

Bockhart,  147,  670.                            De  Cassis,  Vidal,  635. 

Fritsch,  268,  306,  335,  349,  351, 

Boldt,  446.                                          Deletang,  428. 

352,  357,  361,  363,  364,  384, 

Bonnet,  547.                                       De  Morgan,  Campbell,  487. 

387,  439,  441,  497,  498,  499, 

Bou([ue,  635.                                      Deschamps,  507. 

529. 

Bourdon,  178.                                     DeSinety,  21,  218,  219,  267,  311, 

Frommel,  275. 

Bourneville,  666,  667.                             317,  319,  320,  334,  335,  451, 

Fuld,  519. 

Bozeman,   109,   135,   621,  627,           453. 

Furst,  259,  465. 

628.                                                   Diesterweg,  445. 

Brandt,  668.                                          Dirner,  255,  431. 

GALLARD,  287,  339. 

Braun,  Carl,  340,  441,  491,  497.        Dobronrawow,  425. 

Gallippe,  415. 

Braune,  51,  67,  564.                           Dohrn,  23,  515. 

Garrigues,  33,  222. 

Breisky,  30,  471,  514,  515,  522,         Doleris,  328,  516. 

Gehrung,  359. 

535,  551.                                             Donat.  221. 

Geith,  550. 

Brenneeke,  322. 

Doran,  13,  199,  202,  219,  221. 

Gervis,  405. 

Brewis,  389. 

223,  224,  403,  404. 

Gibbons,  313. 

Brinton,  71. 

Dos  Santos,  256,  260,  264. 

Gilmore,  210,  237. 

2  Y 

706 


APPENDIX. 


Goltz,  142,  613. 

Goodell,  188,  209,  237,  270,  507. 

Goodman,  83. 

Gougenheiiu,  547. 

Goupil,  157. 

Graenicher,  53<i. 

Gram,  671. 

'Gray,  261. 

Grechen,  260. 

Greenhalgh,  271,  430. 

Gross,  593. 

Guerin,  40,  46,  72,  157. 

Gusserow,  186,  410,  411;  413, 
415,  418,  419,  466,  468,  471, 
472,  473,  480,  485,  495,  497, 
500,  507,  508,  510,  587,  635. 

Gwilt,  549. 

HABIT,  478. 

Haeckel,  550. 

Hamilton,  157,  237. 

Hanks,  104,  116,  125,  130. 

Hanot,  418. 

Hardon,  275. 

liars]. a.  426. 

Hart,  41,  62,  78,  79,  104,  135, 

186,  272,  375,  380,  567. 
Hasse,  57,  58. 
Hebra,  547. 
Hecker,  558. 
Hegar,  125,  130,  131,  208,  211, 

270,  282,  330,  432,  437,  459, 

532,  536,  623,  636. 
Heinricius,  318,  320,  322. 
Heitzmann,  320. 
Henderson,  261,  529. 
Henle,  10,  30,  32,  38,  51. 
Hennig,  16,  267,  388. 
Henrichsen,  531. 
Herman,  186,  352,  366,  564. 
Hewitt,  Graily,  295,  350,  351, 

359,  360,  361. 
Hicks,  Braxton,  234,  343,  394, 

396,  448. 

Higginson,  137,  138,  139,  610. 
Hildebrandt,  425,  527,  531,  543, 

546. 

Hill,  431. 
Hilton,  638,  640. 
His,  45,  57,  58. 
Hodge,  375,  377,  379. 
Hofmeier,  311,  431,  482,  492, 

497,  498,  501. 
Holden,  551. 
Holdhouse,  418. 
Holdsworth,  515. 
Holl,  33. 
Hollander,  221. 
Horrocks,  422. 
Houston,  37. 
Hubert,  418. 
Hue,  418. 
Huguier,  279, 287.  288,  544,  550, 

567. 

Hunter,  Wm.,  178. 
Hutchinson,    Jonathan,     241, 

503,  550. 
Hyde,  552. 
Hyrtl,  37,  69,  71. 

IMI.A'  H,  186. 

JACOBI,  83. 
Jacubash,  507. 
.laggard,  898. 
Jastrebow,  74. 
Jay,  634. 

Jennison,  116,  120. 
Jobert,  616. 
Johnston,  412. 
Johnstone,  186,  213, 


Jones,  Dixon,  432,  434. 

Mackintosh,  267,  269. 

Jones,  Handfeld,  649. 

Madden,  More,  515. 

Joseph,  33. 

Mahomed,  247. 

Josephson,  618,  635. 

Malassez,  218,  219. 

Malgaigne,  476. 

KAHN'-BKNSINGER,  260. 

Malins,  398. 

Kaltenbach,  212,  330,  400,  466, 

Mann,  431. 

615,  623,  636. 

Marckwald,  273,  282. 

Karstrom,  432. 

Marta,  426. 

Kaschkaroff,  337. 

Martin,  132,  186,  196,  212, 

906, 

Kehrer,  519,  594. 

292,  296,  297,  301,  314, 

327, 

Keith,  145,  240,  241,  242,  244, 

340,  411,  412,   431,  432, 

433, 

246,  249,  428,  429,  436,  441, 

495,  497,  498,  524. 

649,  652,  ti53. 

Martin,  J.  H.,  429. 

Keith,  Skene,  429,  652,  658. 

Mayer,  548,  549. 

Kelly,  382,  431,  440,  441. 

Meadows,  381. 

i    Kemarski,  393. 

Meinert,  299. 

Kidd,  418. 

Meyer,  543. 

Kiderlen,  524. 

Michie,  535. 

Kinkead,  84. 

Mills,  666. 

Kiwisch,  333. 

Miner,  246. 

Klebs,  147,  320,  405,  461,  462, 

Mitchell,  Weir,  341,  662, 

663, 

504. 

664,  666. 

Kleeberg,  437. 

More  Madden,  -.270. 

Klein,  71,  85,  292,  294. 

Morgan,  Campbell,  459. 

Klein  and  Smith,  85. 

Moricke,  88. 

Kleinwachter,    264,    413,   430, 

Morris,  426,  <>-!'.>. 

524,  594. 

Mosler,  199. 

Klemm,  330. 

Miiller,  268,  444,  440,  506, 

578, 

Klob,  275,  333,  415. 

594. 

Klotz,  305,  382,  383. 

Munde,  127,  237,  260,  294, 

296, 

Koch,  147,  148,  149,  166,  199. 

311,  359,  370,  308,  431. 

Koeberle,  186,  382,  436,  437,  442, 

Murphy,  418. 

448. 

Murray,  Milne,  144. 

Kohlrausch,  55,  56. 

Roller,  145. 

NEGRI,  446. 

Kolliker,  23. 

Neisser,  147,  195,  527,  669, 

670. 

Konig,  42,  169, 

Nelaton,  17S,  240. 

Kotschau,  411. 

Neugebauer,  108,  112,  114, 

134, 

Krassowski,  441. 

399,  577,  578. 

Krohne,  245. 

Xieberding,  294,  296. 

Kroner,  395. 

Xitze,  604,  C13. 

Kubassow,  320. 

Xoeggerath,  159,  193,  217, 

218, 

Kuchenmeister,  135,  272. 

291,  292,  333,  394,  395, 

400, 

Kugelmann,  329. 

600,  669. 

Kulenkampff,  549. 

Nonat,  157. 

Kummell,  431. 

Kundrat,  86,  88. 

O'HARA,  446. 

Kunert,  506. 

Ohm,  654,  656. 

Kiister,  411. 

Oldham,  450,  517. 

Kustner,  17,  18,  21,  294,  311, 

Oliver,  515. 

321,  360,  450,  452,  535,  549. 

Olshausen,  181,  203,  219, 

221, 

200,  317,  320,  323,  324, 

325, 

LANDAU,  127,  318,  465. 

382,  415,  497. 

Landowzy,  415. 

Otto,  543. 

Langenbeck,  264. 

Langenbuch,  648,  650. 

PAGE,  521: 

Le  Bee,  46,  72,  157. 

Fallen,  294,  297. 

Lebedinsky,  202. 

Paquelin,  140. 

Leblond,  330. 

Park,  292,  330. 

Lecorche,  547. 

Parkes,  597. 

Lee,  247,  382,  389,  403. 

Patenko,  217. 

Lefort,  577,  578. 

Paterson,  256. 

Leiter,  604. 

Pawlik,  491,  497,  603. 

Lembert,  652. 

Pean,  240,  432,  435,  497. 

Leopold,  21,  72,  82,  88,  186,  264, 

Peaslee,  264. 

316,  318,  382,  383,  404,  443, 

Peckham,  550. 

497,  498,  519. 

Petit,  649. 

Lewers,  492,  493. 

Pfliiger,  216. 

Lister,  130,  244,  246. 

Phillips,  198. 

Litschkus,  266. 

Picot,  471. 

Loswenhardt,  88. 

Pirogoff,  39,  47,  56,  59. 

Lorey,  405. 

Playfair,  W.  S.,  468. 

Lowenstein,  30. 

Plimmer,  446. 

Luschka,  14,  30,  33,  51. 

Polk,  33,  329,  383,  430. 

Lusk,  73,  159. 

Poncet,  401. 

Porak,  535. 

AIACAN,  382. 

Post,  498. 

M'Clintock,  420. 

Pott,  Percival,  204. 

Macdonald,   Angus,   264,    332, 

Pozzi,  5,  6. 

894,  550. 

Priestley,  533. 

INDEX  OF  AUTHORS. 


707 


Profanter,  66S. 
Puech,  523. 

Seseman,  245. 
Seyfert,  480. 

355,  356,  359,  377,  393,   394, 
396,  398,  409,  435,  490,  491, 

Sibley,  471. 

521,  522,  529,  546. 

QUAIN,  74. 

Simmons,  536,  549,  550. 

Thorn,  534. 

RAINEY,  19. 
Ramsbotham,  543. 

Simon,  101,  103,  132,  137,  273, 
282,  488,  533,  599,  600,   601, 
602,  620,  621,  635. 

Thornton,   224,   242,   243,  240 
248,  249,  427,  432,  441. 
Tillaux,  409,  415. 

Ranney,  11. 

Simpson,  A.  R.,  78,  SO,  104,  116, 

Tilt,  532. 

Rayleigh,  656. 

123,  133,  159,  210,  275,   282, 

Times,  407. 

Reamy,  405,  415. 

375,  384,  387,  398,  400,   419, 

Touret,  313. 

Recamier,  132,  178. 

425,  426,  430,  481,  491,  505, 

Trenholm,  210. 

Recklinghausen,  147. 

506,  508,  510,  520,  535,  550, 

Treves,  052. 

Regnard,  666,  007. 

559,  561,  000,  030,  071. 

Tripier,  427. 

Reid,  114,  270. 

Simpson,   Sir  J.  Y.,   115,   123, 

Turner,  21,  37,  74,  408. 

Rein,  432,  441. 

124,  125,  157,  207,  270,  271, 

Reinl,  83. 

274,  275,  277,  329,  333,  356, 

UFFELMAN,  31. 

Reinmann,  332. 

411,  426,  409,  470,  480,  484, 

Underbill,  450. 

Richelot,  497. 

488,  491,  501,  542,  549,  552, 

Richer,  666,  667. 

592,  593,  624. 

VAN  BUREN,  639. 

Richet,  16. 

Sims,   80,   106,   107,   108,  109, 

Van  de  Warker,  59,  494. 

Rieder,  23. 
Rindrteisch,  218. 

110,  114,  116,  119,  128,  129, 
133,  134,  209,  211,  212,   244, 

Vedeler,  265,  267,  208,  352,  366. 
Veit,  21,  22,  303,  304,  431,  432, 

Ringer,  426,  583. 

267,  268,  270,  272,  281,  356, 

461,  462,  463,  464,  465,  471, 

Ritchie,  82. 

374,  493,  494,  530,  593,  620, 

478,  501,502,  534. 

RiTington,  577. 

621,  623,  649. 

Velpeau,  178. 

Rokitansky,  217,  221,  348,  384, 

Sinclair,  186. 

Virchow,  47,  167,  182,  333,  346, 

431. 

Skene,   30,   31,   5tf4,   596,   602, 

404,  407,  413,  445,  453,  461, 

Roger,  291. 

605,  607,  610. 

462,  503. 

Ross,  261. 

Skoldberg,  313. 

Voisin,  185. 

Routh,  271,  824,  881,  882,  487. 

Skutsch,  411. 

Volta,  656. 

Roux,  671. 

Slavjansky,  202,  217,  319,  320, 

Von  Griinewaldt,  266,  593. 

Ruedinger,  38,  47,  49,  57,  92,  639. 

321. 

Von  Hacker,  440. 

Ruge,  22,  303,  304,  305,  307,  316, 

Smith,  Albert,  375,  378. 

Von  Ott,  411. 

319,  320,  363,  432,  461,  462, 

Smith,  Heywood,  311,  382. 

Von  Preuschen,  23,  30,  534. 

463,  404,  405,  471,  478,  501, 

Smith,  Protheroe,  116. 

Von  Rabenau,  382. 

525,  520. 

Smith,  Tyler,  394. 

Von  Volkmann,  499. 

Rummel,  440. 

Solowietf,  587. 

Voss,  561. 

Runge,  398. 

Soyer,  547. 

Vulliet,  330. 

Ruter,  536. 

Spiegelberg,  41,  47,   219,    225, 

Rutherford,  426. 

292,  294,  444,  507,  536. 

WALDEYER,  74,  216,  219,  461, 

Staude,  497. 

462. 

SANGER,  188,  195,  221,  247,  292, 

Steavenson,  428. 

Walter,  446. 

382,  441,  497,  561,  032. 

Stein,  561. 

Warner,  584. 

Sappey,  16,  72. 

Steinschneider,  260. 

Webb,  659. 

Saurenhaus,  466. 

Stephenson,  83. 

Wells,  Spencer,  166,  167,  240, 

Savage,  38,  264,  271. 

Steurer,  146,  159. 

241,  243,  246,  248,  249,  292, 

Siixinger,  480. 

Steven,  199. 

293,  300,  401,  435.  495. 

Scanzoni,  266,  332,  333,  340,  384, 

Stiegele,  549. 

Werth,  221,  247,  204. 

546. 

Stirling,  A.  B.,  149. 

West,  248,  549,  550. 

Schanta,  668. 

Storer,  039. 

White,  394,  395. 

Scharlans,  494. 

Stratz,  279,  293,  478. 

Whitehead,  275,  592. 

Schatz,  188,  564,  565,  60S. 

Sutton,  6. 

Williams,  J.,  68,  69,  85,  86,  88, 

Schlesinger,  43. 

Swiecicki,  446. 

452,  463,  464,  471,  473,  588. 

Schmalfuss,  398. 

Symington,  38. 

Williams,  Wynn,  381,  487. 

Schorler,  400. 

Wilson,  446. 

Schramm,  494. 

TAIT,  LAWSON,  76,  82,  88,  125, 

Wiltshire,  248. 

Schroeder,  16,  65,  66    67,  181, 

130,  186,  192,  193,  197,  198, 

Winckel,   195,   221,    287,    361, 

219,  240,  204,  207    296,  301, 

199,  202,  208,  209,  211,  212, 

413,  526,  596,  005,  618,  619. 

313,  314,  316,  332    350,   357, 

221,  245,  246,  248,  249,  382, 

Winkler,  507. 

390,   404,  408,  415    418,   431, 

389,  398,  408,  431,  441,  442, 

Woodhead,  150. 

432,  433,  452,  471    478,  480, 

446,  561,  575,  646,  649,  051. 

Wyder,  409. 

491,  492,  495,  497    498,  500, 

Tarnier,  149. 

Wylie,  446. 

502,  506,  513,  534    546,  549, 

Tate,  394,  396. 

567. 

Taufer,  264,  431,  441. 

ZELLER,  318,  450. 

Schuckhardt,  536. 

Taylor,  330,  385,  549,  550. 

Zemann,  195. 

Schiicking,  383. 

Terrier,  498. 

Ziegenspeck,  343,  346. 

Schultze,  54,  55,  56,  57,  58,  66, 

Terrillon,  550. 

Ziemssen,  664. 

127,  164,  201,  270,  309,  343, 

Thelen,  441. 

Zinke,  296. 

350,  381,  382,  409,  411,  668. 

Thiersch,  461. 

Zinnstag,  510. 

Schiitz,  569. 

Thin,  550. 

Zwanck,  570. 

Schwartz,  167. 

Thiry,  398. 

Zweifel,  186,  260,  434,  441,  495, 

Semeleder,  237. 

Thomas,  116,  120,  237,  273,  285, 

520. 

Sequiird,  Brown,  666. 

305,  307,  310,  313,  333,  340, 

Zweigbaum,  537. 

INDEX    OF    SUBJECTS. 


Note.—  As  the  student  will  find  in  the  Table  of  Contents  the  sub-divisions  of  each  special 
subject,  we  give  only  one  reference— in  bold  figures— to  the  place  where  each  subject  is 
specially  treated  of.  References  in  other  parts  of  the  book  are  given  in  detail. 

Thus,  for  the  topics  considered  under  "  Carcinoma  Uteri,"  see  that  subject  in  the 
Table  of  Contents ;  for  references  to  Carcinoma,  not  contained  in  the  chapters  on  Carci- 
noma, see  Index. 

For  instruments  figured  in  text,  see  Instruments  in  Classified  List  of  Illustrations. 


ABDOMEN — distension  of,  in  ovarian  tumour  231. 

physics  of  75. 

Abdominal  contents,  relation  to  skin  91. 
examination  90. 
pressure,  action  on  uterus  343. 
regions  91. 
Section  645. 

possible  accidents  651. 
for  pelvic  abscess  186. 
for  carcinoma  494. 
for  fibro  cystic  tumours  446. 
for  fibroids  430. 
in  hsematocele  186. 
for  ovarian  tumours  237. 
for  removal  of  ovaries  211. 
Abortion  and  endometritis  317,  323,  326. 
in  lacerated  cervix  296. 
causing  pelvic  cellulitis  168. 
ovaritis  203. 
peritonitis  159. 
and  fibroids  412,  416,  418. 
and  metritis  337. 
in  retroflexion  348,  34s). 
cause  of  subinvolution  336. 
Abscess— pelvic  168,  186,  650. 

opened  by  cautery  172. 
tapping  of  172. 
of  uterine  wall  332. 
Adenoma  318,  447,  450,  452,  460,  465. 
Adhesions — in  anteversion  357. 
in  fibroids  408. 
in  retroflexion  367,  371. 
in  retro  version  361. 
diagnosis  in  ovarian  tumours  235. 
produced  by  ovarian  tumours  247. 
treatment  in  ovarian  tumours  243. 
Age — influence  on  carcinoma  471,  501. 
on  sarcoma  507. 
on  fibroid  tumours  415. 
in  relation  to  hsematocele  181. 
to  menstruation  82. 

Alexander- Adams  operation  382,  574,  577. 
Amenorrhcea  582. 

due  to  atresia  516,  582. 
in  chlorosis  582. 
and  endometritis  322. 

phthisis  582. 
physiological  582. 
in  superinvolution  277. 
Ampere  656. 

Ampulla  of  Fallopian  tube  23. 
Amputation— of  cervix  281,  340,  382,  488. 

hypertrophied  in   prolap- 
sus 288. 
of  inverted  uterus  399. 


Ansemia  in  hsemorrhagic  endometritis  323. 
carcinoma  476. 
cervical  catarrh  310. 
inversion  389. 
Anaesthetics  140. 

Anteflexion  of  uterus  343,  345,  347. 
Anteflexion  and  small  fibroid  tumour  421,  422. 
pathological  1C2,  173. 

mistaken    for    retrover- 

sion  34S,  361. 
passage  of  sound  in  118. 
Anteversion  of  uterus  344,  345,  356. 

due  to  chronic  metritis  357. 
Antiseptics  in  gynecology  147,  646. 
Antiseptic  douche  139,  151,  311. 

injections  in  carcinoma  485. 
Anus  38. 

fissure  of  640. 

producing  vaginismus  531. 
Apostoli's     method     of     electrical     therapeutics 

652. 

Areolar  hyperplasia — of  cervix  307. 
of  uterus  333. 

Arsenic  in  membranous  dysmenorrhoea  589. 
Ascites  and  ovarian  tumours  232,  234-. 
Aseitic  fluid  in  malignant  ovarian  disease,  159, 

222,  224. 

Asphyxia  from  chloroform  144. 
Atresia  of  cervix  uteri  265. 
senile  319. 
of  hymen  512. 
in  septate  uterus  523. 
of  vagina  512,  513. 
operation  for  519,  520. 
Atrophy  of  cervix  and  uterus  274. 

congenital  of  uterus  258,  260,  263 
senile  277. 
Auscultation  93. 

and  fibroids  422. 
and  ovarian  tumour  232. 
Axial  Coronal  Section  49,  63. 

BACTERIA,  in  cellnlitis  168. 
wi  erysipelas  146. 

Baden-Baden  waters  in  chronic  metritis  339. 
Barnes'  ointment-positor  329. 

speculum  for  vaginal  tampons  312. 
Bartholinian  glands  11. 

cysts  of  547. 
inflammation  of  544. 
abscess  in  548. 
Battey's  operation  87,  208. 

in  dysmenorrlinea  590. 
in  fibroids  442. 
Benzoate  of  ammonia  in  cystitis  P10. 


710 


APPENDIX. 


Bimanual  Examination  96. 

in  antetlexion  353,  354. 
in  early  pregnancy  338. 
in  fibroids  420,  42:i. 
in  inversion  391,  392. 
position  of  hands  in  '.T>. 
to  replace  retroflexed  uterus  371. 
in  retroflexion  31:7. 
in  retroversion  :ioi. 
with  sound  123,  281. 
for  stone  in  bladder  612-613. 
in  uterine  displacements  348. 
Biniodide  of  Mercury  as  an  antiseptic  150. 
Bipolar  method  of  applying  electricity  057,  COO. 
Bladder,  Anatomy  of  30,  596. 

afl'ection  of,  in  carcinoma  4150,  409. 

in  amputation  of  cervix  289. 

calculi  in  612. 

changes  in,  after  fistula  617. 

changes  in  position  of  33. 

diastole  of  35. 

dilated  in  carcinoma  469. 

displacements  of  607. 

in  retroflexed  gravid  uterus  608. 
distended,  and  ovarian  tumours  234. 
functional  diseases  of  613. 
injuries  to  in  ovariotomy  243. 
malformations  of  005. 
methods  of  exploring  599. 
neoplasms  of  608. 
openings  32. 

perforation  by  calcified  fibroids  419. 
peritoneal  relations  289. 
physiology  of  596. 
position  :!0. 

changes  in  34. 
in  inversion  of  uterus  387. 
pressure  on,  by  fibroid  tumour  418. 
in  retroflexion  343,  303,  365. 
shape  when  empty  34. 

in  foetus  35. 
structure  30. 

systole  and  diastole  of  597. 
effect  of  its  distension  on  the  uterus  55, 

59,  343,  300. 

Blaud's  pills  in  chlorosis  583. 
Blistering  of  the  cervix  uteri  340. 
Blood  effusion  into  pelvis  178. 

in  broad  ligaments  179. 
and  ovarian  tumour  230. 
Blood-vessels  of  pelvis  68. 
Bougies  graduated  to  dilate  cervix  209. 
in  anteflexion  355. 
in  fibroids  423. 
Bozeman's  scissors,  136. 

speculum  108. 

Brandt's  pelvic  gymnastic  668. 
Breisky's  instruments  for  operating  in  atresia  522. 
Bright's  disease  in  fibroid  tumour  418. 
British  Association  (B.A.)  electro-magnetic  units 

656. 
Broad  ligament  40. 

affections  of  187. 
anatomy  18,  45. 
blood  effusion  into  179. 
connective  tissue  of  42,  46. 
cysts  of  226. 
new  growths  in  187. 
position  45. 
tumours  of  187. 

and  fibroids  of  uterus 

4-2-2. 

Bromide  of  Potassium  in  chronic  metritis  340. 
in  fibroid  tumours  426. 
in  ovaritis  204. 

Bromine  solution  in  carcinoma  485,  487. 
Bulbocavernosi  10. 
Bulbi  vaginas  10,  74. 

CACHEXIA  in  carcinoma  476. 

in  sarcoma  508. 
Calcification  of  fibroid  tumours  408,  411. 


Calculi  in  bladder  612. 
Cancer  (see  Carcinoma). 
Carbolic  acid— activity  of  149. 

in  cervical  catarrh  31]. 
in  endometritis  326. 
in  metritis  333. 
in  pruritus  vulvse  546. 
Carcinoma — of  bladder  008. 

of  cervix  460,  474,  483. 

cure  by  amputation  -Iss. 

commencement  in  cervix  310. 

development  404. 

duration  of  life  in  480. 

and  endometritis  3 •_'.">. 

extension  to  neighbouring  organs  46(i. 

of  Fallopian  tubes  I'.i'.t. 

in  male  and  female  compared  469. 

affecting  fibroid  tumours  412. 

combined  with  sarcoma  504. 

contrasted  with  fibroid  402,  477. 

diagnosis  from  sarcoma  50'.'. 

spontaneous  cure  of  480. 

spread  of  405,  480. 

of  body  of  uteius  500. 

of  ovary  224. 

of  vagina  535. 

secondary  4  78. 
of  vulva  549. 

Carlsbad  salts  340,  583,  043. 
Case-taking,  method  of,  671. 

A.  R.  Simpson's  card  for  672. 
Cataleptic  convulsions  and  lacerated  cervix  295. 
Catarrh  of  cervix  302. 

and  carcinoma  471. 

laceration  293,  307. 
retroflexion  307. 
diagnosis  from  vaginal  309. 
of  uterus  315. 
Oatarrhal  patches  300,  324. 
Catheter — methods  of  passing  590. 
Skene-Goodman  611. 
stationary,  for  fistula  032. 
Cauliflower  excrescence  4~>:',,  470. 
Caustics  producing  atresia  206. 

metritis  337. 
in  carcinoma  487,  4 '.'::. 
in  cervical  catarrh  313. 
Cautery  in  dividing  cervix  429. 

in  incising  capsule  of  fibroid  429. 
in  laparotomy  for  fibroids  435. 
in  ovariotomy  _  ii'. 
Paquelin's  140. 
in  sarcoma  510. 
in  opening  vaginal  cysts  ">34. 
in  obliterating  vesical  fistula;  634. 
Cellular  tissue  of  pelvis,  haemorrhage  into  182. 

(r.  Connective  tissue). 
Cellulitis,  pelvic  167. 

and  anteflexion  173,  340,  352,  354. 
diagnosis  from  anteversion  359. 
producing  lateri  version  173. 
and  lacerated  cervix  293. 
ovarian  tumours  '-'30. 
subinvolution  330. 
relation  to  peritonitis  157,  158,  169. 
and  retroflexion  309. 
in  utero-sacral  ligaments  173,  350,  355. 
Cervical  catarrh  in  lacerated  cervix  293. 
chronic  300. 
with  retroflexion  303. 
endometritis  300. 
mucus,  character  of  308. 
plug,  Thomas'  273. 
polypus  4.riO. 
Cervix— amputation  of  281,  288. 

flap  operation  288. 
in  carcinoma  488. 
compared  with  extirpation 

of  uterus  , 
in  prolapsus  •>•-. 
producing  involution  340. 
anatomy  16. 


INDEX  OF  SUBJECTS. 


711 


Cervix — areolar  liyperplasia. 
atrophy  of  214,  320. 
atresia  of  265,  517. 

operation  for  ~rl-l. 
cancer  of  (see  carcinoma), 
carcinoma  of  460,  474,  483. 
catarrh  of  302. 

chronic  thickening  of  2G6,  209,  280. 
conical  200,  209,  280. 
closure  for  vesico-uterine  fistula  032. 
connective  tissue,  increase  of  307. 
cysts  of  300. 

degeneration,  granular  and  cystic  305,  310. 
descent  in  prolapsus  .V>7. 
dilatation  of  125,  269,  429,  449. 
division  of  270,  420. 

antero-posterior  356. 
bilateral  272,  350. 
examination  of  95. 
excision  of  273,  313. 
fibroid  tumour  of  403,  412,  441. 
glands  of  21,  307. 
hypertrophy  of  200,  279,  312. 

three  forms  of  287. 
in  cancer  478. 
in  prolapsus  509. 
induration  of,  in  carcinoma  478. 
inflammation  307. 
in  infantile  uterus  258,  263. 
position  in  inversion  oS7,  390." 
laceration  of  290. 

producing  cellulitis  168. 

cervical     catarrh 

307. 

parametritis  175. 
lymphatics  72. 
medication  in  catarrh  311. 
mucous  membrane  of  20,  303,  307. 
normal  structure  contrasted  with  patho- 
logical 300. 

obliteration  of  canal  420. 
papilloma  of  452. 
position  in  antettexion  350. 

retroversion-j-retronexion302. 
rigidity  of  200. 
rupture  in  atresia  513. 
sarcoma  of  502. 
stenosis  of  260. 
stitching  297. 
in  superinvolution  274. 
supra-vaginal  amputation  of  491. 
"  ulceration  "  of  295,  303. 
ulcerations,  true  300. 
vaginal  portion  of  16. 
Champignons  cancereux  470. 
Channelled  polypus  450. 
Childbirth  producing  cellulitis  168. 

peritonitis  159. 
Chill  producing  cellulitis  168. 
ovaritis  203. 
peritonitis  159. 
Chloral  in  carcinoma  485. 
Chloride  of  zinc  in  carcinoma  494. 

vaginitis  529. 
Chloroform — action  of  140. 

administration  of  143. 
dangers  from  ]  44. 
uses  of  142. 

Chlorosis,  amenorrhosa  in  582. 
leucorrhoea  in  321. 
small  uterus  in  25S,  274. 
Cholera  and  endometritis  321. 
Chromic  acid — in  cervical  catarrh  311. 

in  endometritis  327. 
Chronic  cervical  catarrh  300. 

metritis  and  fibroid  tumour  421. 
Cintrat's  serre-noeud  436. 
Clamp  in  ovariotomy  241. 

disadvantages  of  241. 
in  laparotomy  for  fibroids  435,  437. 
Clitoris — anatomy  4. 

development  of  74,  541. 


Cloaca  541. 

persistence  of  541. 
Cocaine  145. 

in  vaginismus  532. 
Coccygeus  12. 
Coccygodynia  644. 
Colpitis  525. 

emphysematosa  526. 

Conception  in  an  undeveloped  horn  260,  263. 
Constant  electric  current  654,  657. 
Connective  tissue  of  pelvis  41,  40,  47. 

as  seen  in  sections  43,  46,  47. 
methods  of  studying  42. 
new  growths  in  187. 
relation  to  cellulitis  168. 
studied  by  injections  42. 
spread  of  carcinoma  in  465,  466, 

469. 

tumours  of  189. 
of  uterus,  increase  of  in  metritis 

334. 
Connective-tissue  origin  of  cancer  461. 

sarcoma  503. 
Constipation  643. 

in  fistula  619. 
Copraemia  476. 
Coronal  Section  48. 
Corpus  luteum  of  menstruation  and  pregnancy 

84. 
Corrosive  sublimate  as  an  antiseptic  149. 

in  metritis  333. 
Coulomb  656. 

Cradle-pessary  of  Graily  Hewitt  359. 
Crede's  method  of  expressing  placenta  388. 
Cretinism  and  amenorrhoea  582. 

atrophy  of  uterus  258. 
Curette  132,  327. 

cases  in  which  useful  132. 
Martin's  132. 
method  of  use  133. 
nail,  A.  R.  Simpson's  430. 
Becamier's  132. 
Simon's  132. 
Thomas'  132. 
in  carcinoma  488,  502. 
in  cervical  catarrh  313. 
in  endometritis  320. 
in  diagnosis  of  small  polypi  455. 
in  sarcoma  uteri  510. 
Cystic  fibroid  tumours  443. 

leio-myoma  445. 
Cystitis  609. 
Cystocele  608. 

in  prolapsus  569. 
Cysto-fibroma  443. 
Cystoma  malignum  222. 

ovarii  219. 

Cysts  in  the  cervix  306. 
of  vagina  533. 
of  vulva  547. 

DEFECATION — mechanism  of  638. 

difficult  in  haematocele  184. 
painful  in  carcinoma  476. 

in  retroflexion  366. 
want  of  control,  in  ruptured  per- 
ineum 557. 
Dermoid  cysts  221. 

of  genito-urinary  organs  215,  226. 
Development— intra-uterine  periods  of  259. 
of  myoma  413. 
of  pelvic  organs  74. 
of  the  genito-urinary  organs  215, 

540. 
of  uterus,  period  of  251. 

relation    to    malforma- 
tions 253,  259. 
Diabetes,  pruritus  in  545. 
Diagnosis — sound  in  121. 

volsella  in  105. 

Diathesis— strumous  and  tubercular  258,  310,  325. 
syphilitic  325. 


712 


APPENDIX. 


Diet  in  carcinoma  485. 
in  peritonitis  163. 
Weir  Mitchell's  system  of  841,  663. 
Diffuse  proliferation  of  connective  tisane  333. 
Digestive  derangements  in  anteversion  ::.'i7. 
carcinoma  476. 
endometritis  323. 
Digital  pressure    in  vaginal  fomices,   effects   on 

uterine  position  80. 
exploration  of  bladder  600. 
Dilatation  of  cervix  125. 

by  rapid  method  458. 
of  uterine  canal  330. 
Dilators— Tail's,  Hanks',  and  Hegar's  130. 

various  forms  of  269. 
Diphtheritic  inflammation  and  carcinoma  478,  479. 

of  vagina  527. 
Discharge — foetid,  in  carcinoma  474,  475. 

of  body  of  uterus 

502. 

watery,  in  sarcoma  uteri  508. 
Discus  proligenis  26. 
Displacements  of  pelvic  floor  62,  562. 
of  uterus  342. 

due  to  cellnlitis  40,  173. 
fibrocyatic  tumours 

443. 

hiematocele  181. 
ovarian      tumours 

231. 

peritonitis  173. 
relation  to  chronic  metri- 

tis  337. 
endonietritis 

321,  322. 

diagnosed  with  sound  121. 
etiology  345. 

physiological  and  patho- 
logical ::»:{. 

produced  by  volsella  105. 
Douche,  forms  of  137. 

in  chronic  metritis  339. 
Douglas,  pouch  of  39. 
Drainage  of  abscess  172. 

in  extirpation  of  uterus  497. 
for  ovarian  tumour  237. 
in  ovariotomy  244. 
tube  in  displacement  of  uterus  383. 
Dressing  of  wound  in  ovariotomy  244. 
Drop-cork  for  chloroform  144. 
Dysmenorrhit-a  585. 

congestive  586. 

mechanical  and  congestion  theories 

of  351,356. 

relation  to  Battey's  operation  209. 
in  anteflexion  351. 
cellulitU  IT:.'. 
stenosis  of  cervix  267. 
endometritis  320. 
fibroid  tumours  415,  417. 
uterine  polypi  453. 
retroflexion  365,  3(56. 
membranous  587. 
obstructive  267,  351. 
spasmodic  586. 
with  sterility  592. 
Dyspareunia  in  anteflexion  353. 
in  peritonitis  161. 
causes  531. 
definition  531. 
in  prolapsed  ovary  206. 
treatment  531. 
in  vaginismus  531. 

ECHINOCOCCI  of  pelvic  organs  188. 
Ecraseur— in  amputating  cervix  281,  488. 
mode  of  application,  489. 
for  removal  of  ovaries  210. 
polypi  459. 

and    galvano-cautery,    relative   atl van- 
tages 4S8. 
Eotropium  of  cervix  294,  305. 


Elastic  ligature  in  amputating  uterus  400. 

in  lajHtrotoiny  for  fibroids  435, 
Electric  endoscope  004. 

apparatus  ami  instruments  659. 
Electricity  in  cervical  catarrh  :ti:;. 
endometritis  329. 
tilnoicls  4'_'7. 
gynecology  652,  661. 
metritiH341. 
nerve  prostration  663. 
Electrodes  656,  659,  660. 
Electrolysis  656,  657. 

in  ovarian  tumour  237. 
Electro-magnetic  units  655. 
Elythrytis  525. 
Elytrorrhaphy  573,  576. 
Emaciation  in  carcinoma  476. 
Emmet's  operation  for  lacerated  cervix  •!'.>'. 
Ems,  waters  of,  in  endonietritis  329. 

in  chronic  metritis  339. 
Endocervicitis  300. 
Endometric  applications  328. 
Endometritis  315. 

relation  to  abortion  317. 

in  anteflexion  3."i4. 

cervical  300. 

and  cervical  catarrh  309. 

leading  to  chronic  metritis  337. 

classification  320. 

diagnosis  by  sound  121. 

fundal  324. 

fungosa  of  Olshausen  317. 

hwruorrhagic  type  and  carcinoma  of 

the  body  502. 
and  sarcoma  509. 
varieties  of  316. 
villous  or  papillary  form  319. 
Endoscope,  electric,  604. 
Enterocele,  vaginal  578. 
Enucleation  of  fibroid  tumours  404,  410. 
spontaneous  404,  409,  419. 
artificial  420,  430,  431. 
ovarian  tumours  245. 
Episioperineorrhaphy  573,  :>7  •. 
Epispadias  543. 
Epithelial  cells  found  in  carcinoma  478. 

origin  of  cancer  4iil. 
Epithelioma  of  the  cervix  4iil. 
and  inversion  389. 
Erector  clitoridis  10. 
Ergot  and  carcinoma  484. 

chronic  metritis  340. 
endonietritis  325,  326. 
fibroids  4'J'i. 

methods  of  administration  in  menorrhagia  58 
Ergotine — hypodermic  injection  of  42i>. 
in  treatment  of  fibroids  IL'".. 
Erosion— follicular  304. 

and  carcinoma  471. 
papillary  304. 

and  carcinoma  478 
simple  303. 

Esthiomene  of  vulva  550. 
Ether  141. 
Ethidene  141. 

Eversion  of  lips  of  cervix  20",  -J'.'". 
Evolution  —  relation    to    jiathology    of    ovarian 

tumour.-  •_'•_' 7. 
Examination  of  cases  671. 

methods  of  90. 
posture  in  133. 

routine  described  in  inversion  391. 
Exanthemata  and  endometritis  3-J1. 
vaginitis  in 
atresia  vagina;  aft. 
External  genitals— anatomy  3. 

development  74,  ">40. 
relation  in  erect  p<»tuu'  ''.. 
examination  of  94. 
lymphatics  of  72. 
Extirpation  of  cance'r  IM>. 

uterus- -for  fibroids  432. 


INDEX  OF  SUBJECTS. 


713 


Extirpation  of  uterus— through   abdominal  walls 

4M. 

through  vagina  495. 
compared    with    amputa- 
tion of  eerrix  497. 
for  sarcoma  510. 

Extra-peritoneal  blood  effusion  181. 
signs  of  184. 

ovarian  tumour,  treatment  245. 
treatment  of  fibroids  433,  435. 
Extra-uterine  gestation  660. 

and  fibroid  tumour  424. 
f*n*tng  hsematocele  181. 
and  ovarian  tumours  230, 

231. 

Exudations  in  the  pelvis  140. 
coarse  of  109. 


FACIBS,  cancerous 

Fallopian  Tubes-anatomy  22. 

abnormalities  193. 
blood-sacs  in  513. 
catbeterisation  of  193. 
development  of  74. 
distent  ion  with   pus  or   blood 

197,198. 
•::v  •-:  •  •__. 
enlarged,  and  fibroid  tumours 

422. 

functions  198. 
hydrops  of  198. 
inflammation  of  195. 
new  formations  of  199. 
palpation  of  193. 
patnlous  condition  of  194. 
position  2t,  45. 
in  inversion  387. 
removal  by  abdominal  incision 

198,211. 

per  Taginam  212. 
affected  with  sarcoma  505. 
stricture  of  194. 
-:r  .   km  |    . 
tumours  of  199. 
Faradic  current  654,  C59,  600. 
Fatty  degeneration  around  polypoidal  fibroid  384. 

in  fibroid  tumour  411. 
Fertility,  standard  of  592. 
Fevers  causing  ovaritis  203. 
Fibrocystic  tumours  of  the  uterus  443,  049. 

and  ovarian  tumours  234. 
Fibroid  tumour  of  uterus  402, 416, 426,  649. 
producing  anteflexion  350. 
and  anteflexion  354. 
Batter's  operation  for  209. 
compared  with  carcinoma  477. 
and  chronic  metritis  337. 
and  gestation  in  detached  bom  268. 
+  inversion  388,  389. 
pediculated  submucoos  447. 
rapidity  of  growth  405. 
relation  to  age  415. 
removal  through  abdomen  430. 

per  Taginam  429. 

sloughing  and  carcinoma  478,  479,  502. 
and  retroflezion  387. 
sarcomatous  degeneration  of  505. 
and  sarcoma  509. 
and  Tail's  operation  213. 
tumour,  spontaneous  expulsion  of  448. 
tumours  of  vagina  535. 

eerrix  403,  412. 
ovary  223. 

Fibromata  of  vulva  549. 
Fibre-myoma  uteri  40:;. 

lymphangiektode*  444. 
Fibrous  tumour  of  uterus  (See  Fibroid). 
Fimbriated  end  of  Fallopian  tube  23. 
Flexions  of  uterus  344. 
Flooding,  producing  cupel-involution  .' 

(See  Hemorrhage). 
Foetal  heart— in  diagnosing  pregnancy  338,  424. 


Foetal  life—  malformations  arising  in  259. 
Foetus  in  detached  born  of  uterus  200. 
Forceps  used  for  extracting  mucous  polyi  458. 
and  fistula  619. 


rneum       . 
Pornioes—  anatomy  of  28,  condition  of,  in  peri- 

tonitis and  cellnlitis  109. 
effect  on  uterus  of  digital  pressure  in  80. 
examination  of  95,  9*. 
lateral  45. 

operation  for  tear  into  301. 
:•  sjtfl  :.    f.  :n  •  •.•-••.:    nUad  Mrfftl  ML 

287. 
Fossa  naricularis—  anatomy  6. 

irritability  producing  vaginis- 

mus531. 
Fourcbette,  anatomy  3. 

fissures  in,  producing  vaginismus  531. 
Freund's  extirpation  of  uterus  494. 
Friedrichshall  water  340,  583,  643. 
Fritach's  method  of  treating  pedicle  of  fibroid  439. 

GALL  BLADDER,  laparotomy  for  distended  C49. 
Gal  vanicor  "Gal  vano-causUc"  current  654,  657,  600. 
Galvanism  278. 
Galvano-Caustic  Wire  in  removal  of  polypi  459. 

for  amputation  of  inverted  uterus  401. 

in  amputating  cervix  281. 

compared  with  eenseur  488. 

mode  of  application  490. 
Galvanometer  664,  659. 
Galvano-  puncture  658. 
Gangrene  of  fibroid  tumour  408. 
Gartner's  canals  23,  74,  227. 
Gehrung's  anteversion  pessary  359. 
Generative  organs,  development  of  227. 
Genito-nrinary  organs  199. 
Gennpectoral  posture  77. 

in      replacing      retroverted 

uterus  371,  374. 
Germinal  vesicle  27. 
Gestation—  Abdominal  650,  651. 

in  detached  horn  200.  263,  650,  651. 

in  Fallopian  tube  650,  651. 

in  a  septate  uterus  261. 
Glycerine  plug,  making  of  204. 
Gonococcns  147,  527,  669. 

examination  in  pus  671. 
cervical  cat 


Gonorrbt 


I  catarrh  307. 


;. .-  • . 

ovaritis  203. 
peritonitis  159. 
sahnfagitis  195. 
raginitis  525,  527. 
and  disfasfs  of  women  669. 

endometritis  320,  321. 
latent  in  the  male  159,  670. 
ami  metritis  331. 
micrococci  in  147,  527,  670. 

Gonorrhoea!  vaginitis,  diagnosis  from  simple  529. 
Gouty  diathesis  and  dysmeoorrbcea  590. 
Graafian  follicles — degeneration  of,  and  ovarian 

cysts  217. 
development  216. 
distention  of,  and  ovarian  cysts 

217. 

number  25. 
position  25. 
rupture  of  84. 
-:r:'.-:  • .;-  M  . 
Greenhalgh's  intra- uterine  stem  355. 

HJEMATOCELE— pelvic  177. 

^»wi  hsBtnatoma  177. 

rupture  of  extra-uterine 

gestation  181. 
fibroid  tumour  424. 
Hsematokolpos  (Bee  Atresia  Vagina;). 
Hsematoma  178,  184 ;  of  vulva  551. 
Haematosalpinx  198. 
H.-:-     :::  Ml    '     •'      •*•!     :.     '.     •"•    ^  -'-'' 

in  carcinoma  uteri  474,  482, 484. 


714 


APPENDIX. 


Haemorrhage  in  carcinoma  of  body  of  uterus  502. 
causing  death  in  carcinoma  480,  482. 
in  carcinoma,  treatment  of  484. 
in  endometritis  320,  322,  825. 
in  fibroid  tumours  410,  424. 
fatal  from  fibroid  tumours  417. 
into  bladder  after  operation  for  fistula 

(538. 

internal,  in  operation  for  atresia  519. 
intra-peritoneal  and  extra-peritoneal 

181. 

in  inversion  of  uterus  889. 
into  the  peritoneum  of  pelvis  178. 
in  polypi  453. 
post-partnm  297. 
in  retroversion  361. 
in  sarcoma  uteri  508. 
secondary  after  ovariotomy  245. 
in  uterine  polypi  453. 
Hsemorrhoidal  plexus  71. 
Heart,  action  of  chloroform  on  145. 
Hernia  and  hydrocele  188. 
Hegar's  amputation  of  cervix  282. 
dilators  131. 
method  for  laparotomy  for  fibroids  430. 

treatment  of  pedicle  437. 
Heredity,  influence  on  carcinoma  471. 
Hermaproditism  542. 

false  543. 
true  542. 
Hernia  of  fibroid  tumour  40S. 

of  ovary  204. 

Hernial  nature  of  prolapsus  566. 
Hewitt's  (Graily)  cradle-pessary  359. 
Higginson's  syringe  137. 
Hodge  pessary  375,  376. 

mode  of  action  378. 
Houston,  valve  of  37. 

Huguier's  conoid  amputation  of  cervix  288. 
Hunyadi  Janos  water  340,  643. 
Hydatid  of  liver  and  ovarian  tumour  234. 

tumour  of  pelvis  188,  649. 
Hydramnos  and  ovarian  tumour  234. 
Hydrargyri  pernitratis  liquor  in  cervical  catarrh 

311. 

Hydrastis  canadensis  340,  426. 
Hydrate  of  chloral  and  carcinoma  485. 
Hydrocele  of  round  ligament  187. 
Hydronephrosis  in  cystitis  609. 

in  carcinoma  467. 
Hydrosalpinx  196. 

and  ovarian  tumours  230. 
Hydrops  folliculorum  219. 

tubae  196. 
Hymen — atresia  of  512. 

development  of  515. 

forms  of  5,  6,  7. 

imperforate,  operation  for  520. 

persistent  or  inflamed,  producing  vagin- 

ismus  531. 

small  ulcers  in,  producing  vaginismus  531. 
Hypodermic  injection  of  ergotin  426. 

morphia  164. 

Hyperplasia  areolar  of  uterus  333. 
of  cervix  307. 
Hypertrophy— primary,  of  cervix  279. 

secondary,  of  cervix  279,  286. 
of  mucous  membrane  of  uterus  409. 
of  muscular  wall  of  uterus  409. 
Hypospadias  542. 
Hysterectomy  for  fibroids  432. 
Hysteria  664. 

due  to  ovaritis  203.  • 
in  parametritis  176. 
small  uterus  in  258. 
and  Battey's  operation  210. 
in  superinvolution  277. 
Hystero-epilepsy  666. 

and  Battey's  operation  210. 

ICE-BAGS  in  haematocele  185. 
Ice-cap  245. 


Ice  in  peritonitis  165. 
Incontinence  of  urine  613,  614. 
India-rubber  ring  to  control  hemorrhage  2S6. 
Induced  current  of  electricity  654,  659. 
Induration  of  fibroid  411. 
Infarct  of  uterus  333,  411. 
Inflammation  of  cervix  1507. 
of  uterus  315. 

in  muscular  coat  of  uterus  331. 
of  pelvic  peritoneum  and  cellular 

tissue  157. 
puerperal  331. 

Inflammatory  deposits  and  fibroid  tumour  424. 
Infundibulo-peivic  ligament  25. 
Inguinal  glands  71,  73. 

affection  in  carcinoma  469. 
Injections — intra-uterine  in  carcinoma  485. 

in  endometritis  325,  326, 

330. 

and  metritis  332. 
into  uterus  and  tubes  194. 
dangers  of  194,  527. 
vaginal  311,  312. 
Interstitial  fibroid  406,  409. 

metritis  333. 

Intestinal  obstruction  due  to  fibroid  tumours  418. 
Intestines — in  pouch  of  Douglas  59. 

relation  to  uterus  and  pelvic  floor  59. 
Intra-abdominal  pressure  upon  pelvic  floor  64,  75. 
in  inversion  384. 
in  prolapsus  565,  568. 
and  retroflexion  365. 
action  on  rectum  638. 
Intra-peritoneal  blood  effusion  177. 

signs  of  184. 

treatment  for  fibroids  433. 
Intra-uterine  galvanic  stem  277. 
injections  330. 
medication  328. 
stem-pessary  355,  381. 
Inversion  of  uterus  384. 

caused  by  fibroid  tumour  411. 
diagnosed  from  fibroid  tumour 

420. 

pediculated    fibroid 
with  inflammatory 
adhesions  56. 
mucous  polypus  456. 
mechanism  of  384. 
and  prolapsus  393. 
in  sarcoma  506. 
In  verted  uterus — amputation  of  309. 

replacement  of — Atthill's  method 

395. 

Barnes'  method  395,  396. 
Courty's  method  396. 
Emmet's  method  398. 
Lawson  Tait's  method  398. 
Xoeggerath's  method  395. 
Tate's  method  396. 
Thomas'  method  396. 
White's  method  395. 

Involution  and  operations  on  cervix  332. 
senile  251. 
puerperal  336. 
artificially  produced  by  amputation  of 

cervix  340. 
Iodide  of  potassium  in  ovaritis  204. 

in  chronic  metritis  340. 
Iodine  in  cervical  catarrh  311. 

in  endometritis  327. 
Iodised  phenol  in  endometritis  329. 
lodoform — in  entiometritis  329. 
in  vaginismus  532. 
in  pruritus  vulvae  546. 
Ischio-rectal  fossa  9,  47,  50. 
Isthmus — of  uterus  14. 

of  Fallopian  tube  22. 

KEITH,  clamp  for  fibroids  437. 
Kidney  disease  in  carcinoma  467. 
Kissingen  waters  in  chronic  metritis  339. 


INDEX   OF  SUBJECTS. 


715 


Knives  135. 

Kolpokleisis  635. 

Kraurosis  vulvas  035. 

Kreuznach  waters  in  endometritis  329. 

chronic  metritis  339. 

treatment  of  fibroids  427. 

Kuchenmeister's  scissors  for  dividing  the  cervix 
136,  272. 

LABIA  MAJORA,  anatomy  3. 
hydroceleof  188. 
Minora,  anatomy  3. 
development  74. 
Labour — atony  of  uterus  in  third  stage  of,  due  to 

chronic  metritis  337. 
"missed"  264. 

rapidity  of,  and  lacerated  cervix  294. 
complicated  by  polypus  454. 
protracted,  producing  fistula  618. 
Laceration  of  cervix  290. 

and  carcinoma  471. 
cellulitis  168. 
chronic  metritis  357. 
subinvolution  336. 
of  perineum  555. 
Lactation — effect  on  uterus  if  protracted  275. 

and  subinvolution  336. 
Laminaria  tents  125,  121). 
Langenbuch's  incision  648. 
Laparotomy  (See  Abdominal  Section). 
Lateri-version  of  uterus  345. 
Leeches — application  uf,  to  cervix  312. 

in  peritonitis  165. 

Lefort's  operation  for  prolapsus  377. 
Lembert's  suture  652. 
Leucorrhoea— as  a  symptom  673. 

in  anteflexion  350,  353. 
cervical  catarrh  304,  308. 
endometritis  321,  323,  324. 
hypertrophied  cervix  280. 
lacerated  cervix  295. 
retroflexion  365,  366. 
uterine  polypi  453. 
vaginitis  528. 
vaginal  cysts  534. 
producing  pruritus  54  j. 
Levator  ani  12,  49,  50. 
Ligature  in  ovariotomy  L'42. 
Lineae  albicantes  95. 
Lipomata  of  vulva  549. 
Listerism — in  gynecology  147,  646. 

in  ovariotomy  240. 
Literature,  Gynecological — Sources  of  675. 

Recent  679. 
Lithia  water  in  pruritus  546. 

salts  of,  in  irritable  bladder  613. 
Locomotion    impaired    in    uterine   inflammation 

357. 

Lupus  vulva;  464,  550. 

Lymph,  coagulable— from  fibroid  tumour  444. 
Lymphatics — relation  to  cellulitis  1€S,  169. 

between  glands  and  vessels 

72,  73. 

of  external  genitals  72. 
in  fibroid  tumours  405. 

dilatation  of  443. 
of  rectum  73. 
relation  to  septicaemia  73. 
of  uterus  72. 

dilatation  in  metritis  335. 
of  vagina  72. 
Lymphatic  glands  of  pelvis  71. 

in  carcinoma  465. 
vessels  of  pelvis  72. 

MALFORMATION  of  uterus  253. 

rectal    examination    in 

263. 
Malignant  peritonitis  158,  224. 

tumours  of  the  uterus  460. 
Marckwald's  amputation  of  cervix  282. 
Marriages,  average  productivity  of  592. 


Martin's  operation  for  cervical  catarrh  296,  313. 

enucleation  of  fibroids  431. 
vaginal       extirpation      of 

cervix  495. 
Massage  163. 

general,  in  uterine  disease  341,  663,  667. 
in  pathological  anteflexion  355. 
Medullary  cancer  461. 
Membrana  granulosa  26. 
Menopause  and  Battey's  operation  209. 
changes  in  cervix  after  267. 

in  uterus  after  274,  319. 
in  vagina  after  525,  527. 
influence  on  fibroid  tumours  406,  424. 
premature  582. 
Menorrhagia  585. 

in  anteflexion  350,  353. 
carcinoma  474. 
lacerated  cervix  295. 
metritis  332. 
endometritis  322. 
fibro-cystic  tumour  445. 
fibroid  tumour  410,  416. 
hajmatocele  184. 
inversion  389. 
ovaritis  203. 
peritonitis  161. 
uterine  polypi  453. 
retroflexion  305,  366. 
treatment  by  Battey's  operation  207. 
Menstruation  82. 

and  Battey's  operation  209. 
irregular,  in  cervical  catarrh  308. 

in  laceration  of  cervix  295. 
diminished  in  chronic  cellulitia  176. 
in  endometritis  321. 
absence  in  fistula  619,  636. 
during  gestation  200. 
relation  to  hsBinatocele  182. 
in  metritis  331,  332,  337. 
periodicity  and  duration  83. 
descent  of  polypus  during  449. 
in  an  undeveloped  horn  260. 
in  bicornuous  and  septate  uterus  260. 
and  Tait's  operation  209,  212. 
Menstrual  blood — composition  84. 
origin  85. 
quantity  84. 

character  of  retained  515. 
Mesenteric  tumours  649. 
Metastatic  deposits  507. 
Metritis  312,  315,  331. 
acute  331. 

chronic  312,  333,  346. 
Metrotome — various  forms  271. 

Sir  Jas.  Simpson's  270. 
Micrococci  in  wounds  146,  168. 

gonorrhoea  147,  527,  669. 
Micro-organisms  in  gynecology,  146- 
Microscope — in  carcinoma  uteri  477,  478,  479,  502. 
endometritis  324. 
sarcoma  uteri  509. 
Micturition  596. 

difficult,  in  fibroid  tumour  418. 
hsematocele  184. 
prolapsus  567. 
frequent  (513. 

in  cystitis  609. 
fibroid  tumour  418. 
fixation  of  uterus  357. 
vaginitis  528. 

painful,  in  carcinoma  476. 
Mobility  of  uterus,  ascertained  by  sound  121. 
Monopolar  method  of  applying  electric  current 

657. 

Morcellement  in  fibroid  tumours  433. 
Morgagni,  columnar  and  sinus  38. 

hydatis  227. 

Morphia— methods  of  administration  164. 
in  carcinoma  485. 
in  metritis  333. 
caution  as  to  use  in  dysinenorrhoea  589. 


716 


APPENDIX. 


Mncoid  degeneration  in  fibroid  tumour  445. 
Mucous  membrane  of  bladder  32. 
cervix  21. 
rectum  36. 
urethra  30. 
uterus  20. 
vagina  29,  525. 
polypi  447,  450. 

Miiller,  ducts  of  74,  22(3,  259,  540,  541. 
Musculature  of  bladder  32. 
rectum  36. 
urethra  30. 
uterus  19. 

Myoma  of  ovary  223. 
uteri  403. 
and  anteflexion  354. 

retroflexion  369. 

Myxomatous  degeneration  of  fibroids  411. 
Myxomyoma  445. 

NABOTHII  ovula  306. 
Nabothian  follicles  306. 

pediculated  447,  452. 
Nail-curette,  A.  R.  Simpson's  430. 
Needles  136,  299,  438. 
Nelaton's  forceps  232. 

Nerve-prostration,  systematic  treatment  of  662. 
Nerves — of  pelvis  73. 
Nervous  derangements  in  anteversion  357. 

endometritis  322,  323. 
reflex  symptoms,  and  lacerated  cervix  294. 

retroflexion  364. 

system,  action  of  chloroform  on  142. 
Neugebauer's  operation  for  prolapsus  577. 
Neuralgia  from  pressure  by  fibroid  tumours  418. 

in  lacerated  cervix  295. 
Neuromata  of  vulva  549. 
Nitrate  of  silver  in  endometritis  329. 

vaginitis  529. 

Nitric  acid  in  endometritis  327,  329. 
in  carcinoma  487. 

OBTURATOR  gland  72. 

internals  13. 
Oedema  of  fibroids  411. 
Ohm  656. 
Ohm's  Law  656. 
Omental  tumours  648. 

and  ovarian  233,  234. 
cells  found  in  fluid  from  225. 
Oophorectomy  208. 
Oophoritis  202,  264. 
Opiates  in  dysruenorrhosa  589. 
Opium  in  carcinoma  485. 
Os  externum — contracted  265,  349. 
examination  of  95. 
position  16,  21. 
OB  internum  and  utero-vesical  fold  of  peritoneum 

17,  287. 

Os  uteri,  form  in  nulliparse  and  multiparse  271. 
Ovarian  artery — course  69. 

in  removal  of  fibroids  433. 
•      corpuscles  222. 
fimbria  23,  25. 
fluid  222. 
ligament  25. 
plexus,  of  veins  71. 

Ovarian  tumours  —cystic  215,  229,  236. 
and  fibroids  422. 

amenorrhoea  582. 
fibrocystic  445. 
genesis  of  226. 
malignant  217,  223. 
position  of  93. 
causing  peritonitis  158. 
solid  223, 230. 
Ovaries — Anatomy  23,  215. 
arterial  supply  69. 
cellular  structures  in  219. 
changes  in  at  each  menstrual  period  85. 
colloid  degeneration  of  stroma  218. 
degeneration  of  blood-vessels  217. 


Ovaries — development  74,  227. 
displacements  204- 
epithelial  tubes  217. 
examination  of  102. 
hyperajniia  202. 
inflammation  202. 

and  amenorrhoea  582. 
ligaments  25. 
malformations  200. 
malignant    development    of    connective 

tissue  202,  217. 
disease  of  224. 
measurements  24. 
menstrual  period,  changes  at  83. 
menstruation,  etfect  on  88. 
palpation  of  201. 
physiology  of  216. 
position  23,  45,  58. 

in  inversion  387. 
in  retroflexion  363. 
prolapse  of  205. 
prolapsed  and  fixed  by  adhesions  210. 

retroflexion  369. 
removal  by  abdominal  section  211,  442, 

648. 

per  vaginam  210. 
structure  25. 
in  superin volution  275. 
tumours  of  215. 
in  rudimentary  uterus  254,  260. 
in  uterus  unicornis  254. 
Ovariotomy  237. 

mortality  249. 
normal  209. 
Ovaritis  202. 

and  Battey's  operation  210. 
and  Tait's  operation  213. 
Ovula  Nabothii  306. 
Ovulation  84. 

with  rudimentary  uterus  254. 
Ovum — formation  of  membrana  granulosa  26. 
structure  26. 
passage  into  uterus  84. 

PAIN — in  fissure  of  anus  641. 

endometritis  322,  323. 
carcinoma  uteri  474,  475,  485. 
carcinoma  of  body  of  uterus  501. 
cellulitis  169. 
cervical  catarrh  308. 
endometritis  320,  322. 
fibroids  415,  417,  418. 
inversion  389. 

retention  of  menses  in  atresia  516. 
metritis  333. 
ovaritis  203. 

acute  and  chronic  peritonitis  160,  161. 
prolapsed  ovary  206. 
retroflexion  366. 
sarcoma  uteri  508. 
superin voluti on  277. 
vaginitis  528. 
Palpation,  method  of  91. 
of  fibroids  422. 
Pampiniform  plexus  71. 
Papilloma  of  the  cervix  447,  452. 
Paracystitis  609. 
Parametric  tissue  47. 
Parametritis  167. 

chronica  atrophicans  174. 
posterior,  of  Schultze  168,  350. 
Paravesical  pouch  of  peritoneum  57. 
Parenchymatous  inflammation  333. 

ovaritis  202. 

Parovarial  cysts  226,  230. 
Parovarium  23,  199. 

development  74. 
distension  200. 

Parovarian  fluids,  nature  of  225. 
tumours  200,  225,  227. 

and  ovarian  234. 
Parturition,  effect  on  pelvic  floor  64. 


INDEX   OF  SUBJECTS. 


Ill 


Parturition  and  cervical  catarrh  307. 

repeated  and  carcinoma  473,  501. 

endometritis321,  324. 
Pean's  method  of  laparotomy  for  fibroids  435. 

needle  for  pedicle  435. 
Pedicle— changes  in,  after  ligature  242. 
of  fibroids  409. 
of  polypi  44S. 
treatment  in  fibroid  tumours  433. 

extra-  and  intra-  peritoneal 

methods  compared  433. 
twisting  407. 
of  ovarian  tumour  220. 

examination  232. 
torsion  248. 

treatment  in  ovariotomy  241. 
Pediculated  cystic/follicle  306,  447,  452. 
Pediculation  and  extrusion  of  fibroids  419. 
Pedunculation  of  fibroid  tumours  409,  426. 
Pelveo-peritonitis  157. 
Pelvic  abscess  168,  181,  650. 

bursting  of  171. 
and  vaginitis  529. 
ceUulitis  167. 

and  ovarian  tumours  230. 
connective  tissue  41,  42,  46,  47. 
deposit  in  pouch  of  Douglas  and  retro- 
flexion  369. 
examination,  importance  of  in  carcinoma 

478. 
floor— anatomy,  general  7. 

structural  60. 

displaceable  and  fixed  portions  63,563. 
displacements  03,  563. 
divisions  64. 
fascia  8. 

functions  of  60,  64. 
preventing  downward  displacement 

343. 
affected  by  change  of  posture  76. 

genupectoral  posture  78. 
intra-abdominal  pressure  on  64,  75. 
measurements  on  external  surface  7. 
muscles  10. 
opening    up     of,     in    genupectoral 

posture  78. 
in  parturition  61. 
pubic  segment  61. 
relation  to  parturition  61,  64. 
sacral  segment  61. 
glands  72. 
inflammation  producing  displacement  172, 

346,  357. 

after  stem  pessary  278. 
and  subinvolution  336. 
organs,  development  74. 
ovarian  tumours  producing  pelvic  inflam- 
mations 158. 
peritonitis  157. 

producing  anteflexion  351. 
with  anteversion  173,  358. 
chronic  161. 

and  ovarian  tumours  230. 
producing  retroversion  173. 
producing  small  uterus  275. 
Pelvic-floor  projection  65. 

callipers  for  measuring  66. 

measurements  66. 

effect    of    pregnancy    on 

66,  67. 
segments  61. 

contrast  between  61. 

as  affected  by  genupectoral 

posture  78. 
in  parturition  61. 
Pelvis — blood-vessels  of  68. 

axial  coronal  sections  of  49,  63. 
contents  of  57. 
coronal  sections  of  48. 
genupectoral  posture,  section  in  79. 
sectional  anatomy  44. 
horizontal  sections  47. 


Pelvis— sagittal  lateral  section  45. 
lymphatics  71. 
nervous  supply  73. 
physics  of  75. 
sagittal  mesial  section  45. 
venous  plexuses  70. 

Perchloride  of  iron  to  check  haemorrhage  484. 
caution  as  to  use  484. 
in  sarcoma  510. 
of  mercury  as  antiseptic  149. 
Percussion,  method  of  93. 
of  fibroids  422. 

of  ovarian  tumour  and  ascites  232. 
Perforation  into  peritoneal   cavity  in  carcinoma 

468,  469,  481. 
bladder  and  rectum  by  fibroids 

419,  420. 

Perimetritis  157,  315. 
Perineal  body  11,  38,  40. 

structure  38. 
measurements  38. 
Perineal  muscles  10. 
Perineum — arterial  supply  69. 
development  541. 
rupture  553. 
central  rupture  554. 

operative  treatment  557,  572. 
support  in  parturition  557. 
Perineorrhaphy  573,  574. 
Periovaritis  204. 
Peritoneal  toilette  244,  652. 
Peritoneum — anatomy  of  39. 

of  bladder  39,  41,  63,  289. 

in  parturition  63. 
of  broad  ligaments  40. 
in  carcinoma  468,  469. 

amputation  of  cervix  288. 
prolapsus  566. 
fistula  617. 
inversion  387. 
haemorrhage  into  178. 
inflammation  of  157. 
effusion    into,    and     ovarian    new 

growths  in  18. 
tumour  231. 

method  of  opening  into  647. 
in  relation  to  operations  41. 
in  parturition  41. 
on  sides  of  pelvis  40. 
local  divisions  on  pelvic  floor  57. 
and  rectum  41. 
in  retroflexion  364. 
of  uterus  17,  39. 
on  posterior  vaginal  wall  39. 
vesico-uterine  pouch  of  39. 
Peritonitis— pelvic  157. 

fatal,  and  carcinoma  481. 
relation  to  cellulitis  157,  170. 

fibroid  408. 
malignant  167. 

cells,  found  in  fluid  from 

224. 

and  ovarian  tumours  230. 
superinvolution  275. 
subinvolution  336. 
retroflexion  365. 
after  uterine  injections  194. 
producing  retroversion  360. 
tubercular  166. 

Pernitrate  of  iron  to  check  haemorrhage  484. 
Pessary — intra-uterine  355. 

in  retroflexion  381. 
Meadow's  381. 
Bouth's  381. 
Schultze's  381. 
Williams'  381. 
vaginal — action  of  382. 

Albert  Smith  356,  375,  377. 

in  division  of  cervix  273. 
anteflexion  356. 
anteversion  359. 
in  chronic  metritis  339. 


718 


APPENDIX. 


Pessary,  vaginal — effect  on  position  of  uterus  81. 
in  fibroid  tumour  427. 
Gehrung's  359. 
Hewitt's  cradle  359. 
Hodge  356,  359,  375,  376,  381. 
choice  of  best  form  377. 
mode  of  introduction  377. 
position  and  action  878,  382. 
Meadow's  381. 

medicated,  composition  of  530. 
in  pregnancy  381. 
in  retroflexion  375. 
for  prolapsed  ovaries  200. 
ring  550. 
Thomas'  359. 
Zwanck's  570. 
Pfliiger's  ducts,  a  source  of  ovarian  tumours  216, 

219. 
Phthisis — amenorrhoBa  in  582. 

uterus  in  275. 

Physics  of  abdomen  and  pelvis  75. 
Physiological  activity,  period  of  251. 
Piles  642. 
Placenta— portions  retained,  and  carcinoma  479, 

502. 

metritis  337. 

relation  to  inversion  385,  388,  390. 
Placental  polypi  447,  452. 
Polypes  &  apparitions  intermittentes  449. 
Polypi  of  uterus  443. 

with  endometritis  320,  321. 

fibioids  446. 

producing  Fallopian  tube  gestation  454. 

diagnosis  from  inversion  392. 

producing  inversion  385,  389. 

+  inversion,  diagnosis  of  392,  456. 

mucous  447,  450. 

and  fibrous  contrasted  454. 
placentfil  447,  452. 
Porte-caustique  329. 
Positive  and  negative  poles  658. 
Posterior  fornix,  effect  of  pressure  on  380. 
Posture — effect  on  abdomen  and  pelvic  floor  76. 

relation  to  examination  and  treatment 

183. 
of  patient  in  cellulitis   and  peritonitis 

170. 
Pouch  of  Douglas  40,  45,  57. 

intestines  in  59. 
Pregnancy — and  fibroid  tumours  408,  413. 

advanced,   and  fibroid  tumour  423, 

424. 
early,  diagnosis  338. 

from  fibroid  tumour  421,  422. 
characters  of  uterus  338. 
in  detached  horn  263,  264. 
diagnosis  from  chronic  metritis  339. 
ovarian  tumour  233. 
and  uterus  dilated  from  atresia  516. 
Assuring  of  cervix  in  294. 
and  large  fibroid  tumours  424. 
+  ovarian  tumour  235,  246. 
hypertrophy    of  cervical   glands    in 

307. 

anteversion  of  uterus  in  359. 
sympathetic  phenomena  of,  in  uterine 

polypus  453. 

Presentation  of  head  and  lacerated  cervix  292. 
Prognosis  in  gynecological  cases  674. 
Prolapse  of  ovary  205. 
rectum  639. 
Prolapsus  uteri  65,  393,  565. 

due  to  fibroid  412. 
and  hypertrophied  cervix  280. 
4-  inversion  393. 
mechanism  567. 
retroversion  in  360. 
senile  60S. 
Pruritus  vulvae  545. 

in  carcinoma  476. 

Pseudocyesis  and  ovarian  tumour  234. 
Pseudo-myxorna  peritonei  221,  247. 


Puberty — changes  at  83. 

symptoms  of  atresia  at  516. 
Pubic  segment — of  pelvic  floor  61,  63. 
displacements  61. 
in  bimanual  examination  100. 
in  semiprone  posture  110. 
Pudendal  hernia  551. 
Puerperal  inflammation  321. 

inversion,  frequency  of  388. 

involution  and  metritis  336. 

Puerperium — rapid  development  of  carcinoma  in 

502. 

and  endonietritis  321. 
inversion  384,  388. 
metritis  336. 
peritonitis  159. 
retroflexion  3(55. 
retroversion  360. 
subinvolution  336. 
Pulse — in  hsematocele  184. 

peritonitis  160,  165. 
Pyosalpinx  197. 

and  ovarian  tumours  230. 
and  laparotoniy  650. 

RAKE  for  removing  sutures  285. 
Rectal  examination  101,  639. 

in  atresia  517. 
carcinoma  477. 
fibroids  420. 

hypertrophied  cervix  281. 
inversion  391. 
pathological  anteflexion 

353. 

retroflexion  368. 
snperinvolution  277. 
uterine  malformations  261. 
Simon's  method  103. 
Recto-abdominal  examination  101. 
Rectocele  639. 

and  prolapsus  569. 
Recto-vaginal  fistula  642. 
Recto-vagino-abdominal  examination  10: ;. 
Rectum — anatomy  36. 

diseases  of  639. 
examination  101,  639. 
fibroid  tumour's  pressure  on  41S. 
inflammation  round  175. 
lymphatics  of  73. 
microscopic  structure  37. 
physiology  637. 
position  35. 

in  retroflexion  304,  365,  369. 
structure  36. 

ulceration  in  carcinoma  468. 
displacing  uterus  343. 
connection  with  the  vagina  36,  61. 
Reflex  action  and  chloroform  142,  144. 

disturbances  from  parametritis  atrophieans 

176. 
Reinversion  of  stump  of  amputated  uterus  401. 

inverted  uterus  393. 
Renal  calculi  612. 

tumours  and  ovarian  234. 

laparotomy  for  649. 
Reposition  of  inverted  uterus  394. 
Respiratory  centre  in  chloroform  144. 
Retention  of  uterine  614. 

producing  cystitis  609. 
due  to  fibroid  tumour  41S. 
Retroflexion  312,  343,  345,  362. 

and  cervical  catarrh  307,  312. 
congenital  363,  364. 
and  small  fibroid  tumour  421,  422. 
relation  to  retroversion  360,  362. 
Retro-pubic  fat  deposit  61. 
Retro-uterine  haematocele  184. 

and  ovarian  tumour  231. 
Retroversion  344,  345,  360,  362. 
congenital  300. 
passage  of  sound  in  117. 
caused  by  peritonitis  173,  361. 


INDEX  OF  SUBJECTS. 


719 


Retroversion — action  of  pessary  on  378,  382. 

physiological  and  pathological  344, 

360. 

in  prolapsus  568. 
with  anteflexion  361. 
-t-Retroflexion  344,  345,  362. 
RetroVerted  gravid  uterus  and  ovarian  tumour 

231. 

Rheumatic  diathesis  and  dysmenorrhcea  590. 
Ring  pessary  570. 

with  diaphragm  570. 
mode  of  introduction  570. 
position  in  vagina  570. 
Rosenmiiller,  organ  of  23. 
Round  ligament — anatomy  of  19. 
hydrocele  187. 
and  junction   of    uterine  horn 

and  tube  255. 
new  growths  in  187. 
shortening  for  displacements  of 

uterus  382. 
prolapsus     574, 

577. 

tumours  of  188. 
a  guide  to  parts  of  uterus  255. 
Rupture  of  the  uterus  in  carcinoma  481. 

SACRAL  SEGMENT  of  pelvic  floor  61. 

rupture  of  inferior  angle  555. 
the  supporting  one  64,   557, 

565. 

supporting  pessary  379. 
Sagittal  mesial  sections  45,  60. 

lateral  section  45. 
Salpingitis  195. 
Sarcoma  of  ovary  224. 

connective  tissue  189. 
uterus  400,  503. 

and  carcinoma  478,  479. 
endometritis  325. 
inversion  389. 
vagina  536. 
vulva  550. 
Sarcomatous  degeneration  in  fibroids  412,  445. 

polypus  451. 

Scarification  of  cervix  312. 

Schroeder's  operation  for  cervical  catarrh  296,  313. 
Schultze's  dilator  276. 
Scirrhous  cancer  461. 
Scissors  135. 

Bozeman's  135. 
for  division  of  cervix  272. 
in  amputation  of  cervix  281. 
Hart's  135. 
Kuchenmeister's  135. 
Scrofula,  leucorrhoea  in  321. 

and  congenital  atrophy  of  uterus  25S. 
Sectional  anatomy  44,  60,  63. 
Semiprone  posture  109. 
Septic  matter  causing  cellulitis  168. 
metritis  331. 
Septicaemia— after  amputation  400. 

after  operation  for  atresia  519. 

in  carcinoma  480,  481. 

from  suppuration  of  fibroid  tumours 

419. 

in  inversion  of  uterus  394. 
relation  of  lymphatics  to  73. 
and  metritis  331. 
after  ovariotomy  245. 
after  tents  130. 
Septic  peritonitis  162,  164. 

salpingitis  195. 
Serre-nceud  of  Cintrat  436. 

in  laparotomy  for  fibroids  436. 
Serous  peritonitis  15S,  160. 
Serum,  collection  in  Fallopian  tubes  197. 
Sexual  activity  and  fibroids  415. 

excess  and  endometritis  321. 
Sickness  after  chloroform  145. 
Silk-worm  gut  137. 
Silver-wire  sutures  i:J7. 


Simon^nd  Marckwald's  amputation  of  cervix  282. 
Simon's  sharp  spoon  and  carcinoma  488,  502. 

urethral  specula  601. 

Simpson's  (A.  R.)  amputation  of  cervix  282. 
nail-curette  430. 
repair  of  perineum  559. 
sound  116. 
volsella  105. 
(Sir  J.  Y.)  division  of  cervix  270,  356. 

galvanic    intra-uterine   stem 

277. 

metrotome  271. 
sound  115. 
Sims'  (Marion)  division  of  cervix  357. 

amputation  of  cervix  2S1. 
curette  132. 
dilator  270. 

speculum  108,  296,  309. 
tenaculum  107. 
operation  for  vaginismus  532. 
Skene-Goodman  catheter  611. 
Skene's  urethral  specula  602. 
Smith  (Albert)  pessary  356,  375,  377. 

mode  of  action  377,  378,  379. 
Souffle — uterine,  in  fibroid  tumour  421. 

absence    of,   in  ovarian    tumour 

424. 
Sound — uterine  115. 

combined  with  Bimanual  123. 
in  anteflexion  355. 

hypertrophied  cervix  281. 
endometritis  309,  321,  324,  327. 
metritis  232,  338. 
small  fibroid  tumours  420. 
fistula  620. 

pediculated  submucous  fibroid  455. 
subserous  fibroid  423. 
inversion  391. 
polypus  and  inversion  457. 
polypoidal  fibroid  420. 
chronic  metritis  338. 
retroflexion  368,  373. 
super-involution  277. 
uterine  displacements  346. 
method  of  dressing  327. 
in  replacing  retroflexion  373. 
in  treating  anteflexion  355. 
Spatulse,  vaginal,  529. 
Specula,     vaginal  —  comparative    advantages    of 

various  forms  114. 
Barnes'  crescent  112. 
Battey's  109. 
Bozeman's  108. 
Cusco's  112. 
Fergusson's  111. 
Neugebauer's  112. 
Sims'  108. 
in  cancer  477. 
in  endometritis  324. 
in  lacerated  cervix  295. 
Speculum— anal  639. 

intra-uterine  329. 
urethral  and  vesical  600,  601. 
Spencer  Well's  clamp  241. 
trocar  240. 

Sphincter  ani — externus^3S. 
internus  38. 
tertius  38. 

operation  to  restore  558. 
Splenic  tumours  648,  649. 
Sponge-tents  125. 
Sponges— in  operations  150. 

precautions  as  to  239,  646. 
Spray  in  ovariotomy  246. 
Staffordshire  knot  211. 
Stem— galvanic  intra-uterine  277. 

in  anteflexion  355. 
Sterility  591. 

in  anteflexion  350,  352. 
cellulitis  172. 
cervical  catarrh  308. 
hypertrophied  cervix  280. 


720 


APPENDIX. 


Sterility  in  stenosis  and  rigidity  of  cervix  2(38. 
lacerated  cervix  295. 
dyspareunia  "i:ll. 
endometritis  322,  323. 
stricture  of  Fallopian  tubes  19  J. 
fibroid  tumour  416,  418. 
fistula  619. 
chronic  metritis  337. 
peritonitis  161,  162. 
double  ovaritis  203. 
uterine  polypi  4"j4. 
retroflexion  306. 
sarcoma  507. 
vaginismus  531. 

Structural  anatomy  of  the  pelvic  floor  60. 
Strumous  diathesis  and  endometritis  325. 
Subinvolution  333. 

and  anteversion  367. 

lacerated  cervix  293. 
cervical  catarrh  312. 
with  retroflexion  363. 
Submucous  fibroid  406,  409,  447. 
Subperitoneal  fibroid  406. 
Subserous  pediculated  fibroids  431. 
Subserous     fibroids     and     fibro-cystic     tumours 

443. 

Superfujtation  261. 
Superinvolution  275. 

and  amenorrhcea  582. 
ascribed  to  ovaritis  202. 
Supra-vaginal  portion  of  cervix,  hypertrophy  of 

279,  286. 

amputation  of  the  cervix  491. 
Suppuration  after  cellulitis  169. 

hsernatocele  ISO. 
of  fibroids  412. 
Sutures  137,  299. 

removal  of  285,  300. 
Sympathetic  pain  in  ovaritis  203. 
Syphilitic  salpingitis  196. 

ulceration  and  carcinoma  478. 

of  perineum  555. 
Syringe,  Higginson's  137. 

TAIT'S  graduated  dilators  130,  458. 

operation    for  removal  of    uterine  appen- 
dages 212,  650. 
in  fibroids  442. 
dysmenorrhoea  590. 
Tangle  and  tupelo  tents  125,  129. 
Tapping  in  cellulitis  171. 
hydrocele  188. 
ovarian  tumours  236. 
peritonitis  167. 
Temperature,  reduction  of  165. 

after  ovariotomy  245. 
Tenaculum  -Sims'  107. 

in  diagnosing  lacerated  cervix  296. 
Tents  125. 

clangers  of  129,  269,  321. 
in  stenosis  of  cervix  269. 
Tetanus  in  carcinoma  482. 
Thomas'  anteversion  pessary  359. 
cervical  plug  273. 
spoon-saw  430. 

Tightlacing  and  uterine  displacement  343. 
Torsion  of  pedicle  of  ovarian  tumour  24S. 

for  removal  of  polypi  458. 
Trachelorrhaphy  297. 
Transverse  section  47. 
Transversus  perinei  10. 
Treatment — operative,  in  gynecology  674. 
sound  in  112. 
specula  in  114. 
volsella  iu  106. 
Triangular  ligament  8. 
Trigone  of  bladder  32. 
Trocars  for  tapping  ovarian  cysts  240. 
Tubal  disease  producing  peritonitis  159. 
Tubo-ovarian  cysts  199. 
Tubercular  diathesis  in  superinvolution  275. 
peritonitis  166. 


Tuberculosis  of  vagina  536. 
Type  of  menstruation  84. 

ULCERATIOX  of  Cervix— so-called  295,  303. 

true  306. 
Os  uteri  464. 

Upright  posture  6,  77,  78. 
Urachus  227. 
Urajmia  in  carcinoma  480. 

fibroid  tumour  418. 
Ureter— anatomy  of  32. 

catheterisation  603. 

relation  to  cervix  and  urethra  617. 

dilatation  in  carcinoma  4t'>7. 

due  to  cicatrisation  364. 
compression  by  fibroid  tumours  418. 
opening  of  32. 
position  of  50. 

Uretero-uterine  fistula  015,  018,  t'rJO. 
vaginal  fistula  615,  618,  620. 
Urethra — anatomy  of  30. 

atresia  in  fistula  617,  632. 
caruncle  531,  006. 
development  541. 
dilatation  599,  607. 
direction  30. 
displacements  605. 
exploration  598. 
glands  30. 
malformations  605. 
neoplasms  606. 

pressure  on,  by  fibroid  tumour  418. 
relation  to  vaginal  wall  61. 
stricture  607. 
Urethral  orifice  4. 
Urethritis  007. 
Urethrocele  606. 
Urethro- vaginal  fistula  615,  619. 

+atresia  of  urethra  632. 
Urination,  physiology  of  596. 
Urine — normal  composition  597. 
character  in  cystitis  609. 
examination  in  fibroid  418. 
incontinence  and  retention  613,  614. 

in  fistula  619. 
Uro-genital  sinus  541. 

persistence  of  541. 
Utero-sacral  ligaments — anatomy  of  20. 

cicatricial  contraction  in  168,  350. 
function,  compared  with  pessary 

379. 

stretching  of,  in  retroflexion  364. 
Uterine  appendages,  removal  of  212,  050. 
artery — course  69. 

in  removal  of  fibroids  433. 
catarrh  315. 

cavity — variations  in  length  of  121. 
contractions  —  importance   in    diagnosis 

233,  422. 
mucous  membrane  in  long-standing  endo- 

metiitis  320. 
changes    in,   at    men- 
strual period  85. 
plexus  of  veins  71. 
Uterus — abscess  in  wall  332. 

absent,  or  rudimentary  254,  259,  261. 
amputation  at  os  internum  432. 

of  inverted  399. 
anatomy  14. 

antettexion  343,  345,  347. 
anteversion  344,  345,  356. 
atrophy  274. 
arterial  supply  OS. 
atrophy  and  amenorrhoea  582. 
bicornis  256,  259,  261. 
bipartitus  254,  259. 
body  of,  in  inversion  380. 
carcinoma  460,  474,  483,  500. 

compared   with    disease    else- 
where 499. 

changes  after  birth  259. 
congenital  atrophy  258,  260,  263. 


INDEX  OF  SUBJECTS 


721 


Uterus— congenital  atrophy  and  super-involution 

277. 

corroding  ulcer  of  464. 
curetting  132,  32(5. 
degenerative  changes  411. 
development  74,  251. 
didelphys  255,  259,  261. 
digital  pressure  in  fornices  80. 
dilatation  in  atresia  513. 

for  therapeutic  purposes  330. 
and  perforation  in  carcinoma 

481. 
displacements  342. 

in  large  fibrous  polypi  448. 
ovarian     and     uterine 

tumours  445. 
peritonitis  and  cellulitis 

172. 

divisions  18. 
duplex  259. 
enlargement  of,  in  endometritis  334. 

metritis  338. 
extirpation  of,  through  abdominal  walls 

494. 

through  the  vagina  495. 
in  malformation  2ii4. 
fibroid  tumour  402,  416,  425,  649. 
changes  with  fibroid  tumour  409. 
fibro-cystic  tumours  443,  649. 
changes  in,  at  angle  of  flexion  348,  3(i3. 
glands  20. 
hypertrophy  278. 

in  fibroid  tumour  409. 
in  prolapsus  566,  567. 
impairment  of  function  in  maldevelop- 

ment  260. 

infantile  258,  260,  263. 
inflammation     (endometritis,     metritis) 

315,  331. 

and  amenorrhoea  582. 
inversion  384. 

with  fibroid  411. 
spontaneous  reinversion  393. 
lateri-version  345. 
ligaments  18. 
lower  segment  17. 
lymphatics  72. 
malformations  253. 

and  superinvolution  277. 
measurements  16. 
mobility  58,  104. 
changes  at  a  menstrual  period  85. 
periods  at  which  morbid  conditions  arise 

in  251. 

mucous  membrane  20. 
musculature  20. 
nervous  supply  73. 
one-horned,  inversion  of  3S5. 
operations  for  retaining  in  position  382. 
peritoneum  of  18. 
polypi  447. 

position,  means  of  ascertaining  56. 
changes  with  fibroid  411. 
with  distended  bladder  55,  59, 

343. 

in  genupectoral  posture  80. 
normal  34,  343. 
opinions  as  to  51 . 
physiological    changes    in     58, 

343. 

relation  to  viscera  59. 
pressure  on  bladder  357. 
prolapse  63,  393,  565. 
replacement  of  355,  359,  362,  371. 
retention  in  position  371,  375,  382. 
retroflexion  312,  343,  345,  362. 
retroversion  344,  345,  360,  362. 
sarcoma  503. 
septus  256,  259,  261. 
atresia  of  523. 
shape  14,  53. 
form  in  section  14. 

2z 


\i  terus— stitching  to  abdominal  wall  for  displace- 
ments 382,  383. 
structure  18. 

subinvolution  312,  330,  333,  334. 
superinvolution  275. 
support  of  64. 
tumours  of  402. 

and  metritis  337. 
unicornis  254,  259,  261. 

and  fibroid  tumours  263. 
veins  of  70. 
virgin  type  258. 

VAGINA— Anatomy  27. 

arterial  supply  69. 

atresia  512. 

cancer  of,  primary  535. 

secondary  469. 

cicatrisation  after  fistula  617. 
labour  515. 
menopause  527. 

artificial  closure  for  fistula  635. 
congenital  bands  in  524. 
cysts  533. 

development  74,  540. 
dilatation  in  atresia  512. 
direction  in  upright  posture  27. 
fibroid  tumours  535. 
form  in  section  29. 
in  genupectoral  posture  78. 
inflammation  of  525. 
inversion+inversion  of  uterus  386. 
lymphatics  72. 
menopause,  change  after  527. 
plugging  to  check  haemorrhage  484. 
position  27. 
sarcoma  536. 
structure  of  29. 
tuberculosis  536. 
venous  plexuses  71. 
walls  27. 
Vaginal  cleft  61. 

columns  28. 
enterocele  579. 
examination  94,  422. 

and  ovarian  tumour  232. 

retroflexion  367. 
glands  28. 
glass  plugs  521. 
injection  311,  312. 
method  of  removal  of  ovaries  210. 

of  ovariotomy  237. 
spatulas  529. 
tampons  and  carcinoma  484. 

vaginitis  530. 
orifice — anatomy  5. 

dilatation  of  532. 
division  of  sphincter  532. 
fissures  around,  producing  vagin- 

ismus  531. 
portion  of  cervix  531. 

amputation  of  491. 
hypertrophy  of  279,  287. 
walls — attachments  of  61. 

inversion  in  prolapsus  567. 
length  28. 

and  direction  in  genupei:- 

toral  posture  79. 
Vaginismus  530. 
Vaginitis  525. 

diphtheritic  525,  527. 
gonorrhoeal  525,  527,  528. 
senile  525,  527. 
Varicose  veins,  due  to  fibroid  tumours  418. 

haemorrhage  from,  in  vulva,  552. 
Varix  of  vulva  551. 

Veins,  pelvic — compressed  by  fibroid  tumours  418. 
Venereal  excess,  causing  peritonitis  159. 
Venous  sinuses  round  fibroid  tumours  404,  416. 
Venous  thrombosis  in  carcinoma  480,  482. 
Versions  of  uterus  344,  345. 
Vesical  catarrh  633. 


722 


APPENDIX. 


Vesical  plexus  71. 

Vesico-uterine  fistula  615,617,  620,  032. 

Vesico-vaginal  fistula  616. 

artificial,  for  cystitis  611. 
Vesico-vaginal  septum  615. 
Vesico-vagino-abdominal  examination  100. 
Vestibule— anatomy  5. 

development  of  74,  541. 
Vichy  waters  in  chronic  metritis  339. 
Volsella— description  of  104. 

examination  with  105. 
Hart's  106. 
A.  B.  Simpson's  105. 
with  speculum  110. 
in  superinvolution  277. 
for  introducing  tents  128. 
in  replacing  uterus  375. 
Volt  656. 

Voltaic  current  654,  657. 
Vomiting  in  htematocele  184. 

peritonitis  and  cellulitis  170. 
Vulva — anatomy  of  4. 
atresia  of  541. 
carcinoma  549. 
cysts  547. 
direction  of  6. 
elephantiasis  548. 


Vulva — eruptions  547. 

fibromata  549. 

hiematoma  551. 

haemorrhage  from  varicose  veins  552. 

hernia  551. 

inflammation  544. 

kraurosis  551. 

lipomata  549. 

lupus  550. 

malformations  540. 

neuromata  549. 

pruritus  545. 

sarcoma  550. 

varix  551. 
Vulvitis  544. 

of  children  544. 

WEIR  MITCHELL'S  treatment  of  nerve  prostration 

and  chronic  uterine  disease  341,  662. 
White's  repositor  for  inversion  395,  396. 
Wiesbaden  waters  in  chronic  metritis  339. 
Wire  sutures  in  amputation  of  cervix  283. 

fistula  620. 
Wolffian  bodies  74,  199,  217,  226,  227. 

Zona  pellucida  27. 

Zwanck's  pessary  for  prolapsus  570." 


ATLAS  OF  FEMALE  PELVIC  ANATOMY 


BY 


D.  BERRY  HART,  M.D.,  F.R.C.P.E.,  F.R.S.E., 

LECTURER  ON  MIDWIFERY  AND  DISEASES  OP  WOMEN,  SCHOOL  OF  MEDICINE,  EDINBURGH, 

ETC. 


Pull  Bound  in  Cloth.     Price,  £2,  2s. 

Consisting  of  numerous  Imperial  Quarto  Plates  drawn  from 
nature,  under  the  direct  superintendence  of  the  Author,  and 
copious  Letterpress  explanatory  of  each  Plate. 

Large  Folio,  price  25s. 


THE   RELATIONS 

OF   THE 

ABDOMINAL  AND   PELVIC  ORGANS 
IN   THE   FEMALE. 

Illustrated  by  a  full-sized  Chromolithograph  of  the  section  of  a 
cadaver  frozen  in  the  Genupectoral  position,  and  by  a  series  of 
Woodcuts. 

By  Alexander  B.  Simpson,  M.D., 

PROFESSOR  OF   MIDWIFERY  AND  THE   DISEASES  OF   WOMEN  AND  CHILDREN 
IN   THE   UNIVERSITY   OF   EDINBURGH  ; 

AND 

David  Berry  Hart,  M.D.,  F.B.O.P.E.,  F.R.S.E., 

LECTURER  ON   MIDWIFERY   AND   DISEASES   OF   WOMEN,    EDINBURGH. 


Large  Quarto,  price  IDs.  6d. 


THE  STRUCTURAL  ANATOMY 

OF   THE 

FEMALE  PELVIC  FLOOR. 

BY 
David  Berry  Hart  M.D.,  F.R.C.P.E.,  F.R.S.E., 

LECTURER  ON  MIDWIFERY   AND   DISEASES  OF   WOMEN,    EDINBURGH. 


W.  &  A.  K.  JOHNSTON,  EDINBURGH  AND  LONDON. 


12  Plates,  Imperial  Folio,  price  12$.  6d. 
STUDENT'S   EDITION    OF 

THE    ATLAS    OF 

THE  ANATOMY  OF  LABOUR, 

INCLUDING  THAT  OF 

Full-Time  Pregnancy  and  the  First  Days  of  the  Puerperium. 
EXHIBITED  IN  FROZEN  SECTIONS. 
REPRODUCED  AD  NATURAM. 


A.  H.  F.  BARBOUR,  M.A.,  B.Sc.,  M.D.,  F.R.C.P.E.,  F.R.S.E., 

Lecturer  on  Midwifery  and  Diseases  of  Women,  School  of  Medicine   Edinburgh  ; 

Assistant  Physician  for  Diseases  of  Women  to  the  Royal  Infirmary ;  Assistant  Physician 

to  the  Royal  Maternity  Hospital ;  Physician  to  the  Women's  Dispensary ; 

Corresponding  Fellow  of  the  Royal  Academy  of  Medicine,  Turin. 


PREFACE  TO  STUDENT'S   EDITION. 

Inasmuch  as  Anatomy  furnishes  the  true  basis  of  knowledge  in  Obstetrics, 
as  in  all  departments  of  Medicine,  I  have  in  preparing  another  edition  of 
this  Atlas  brought  it  out  in  a  form  which  will  place  the  results  of  the 
Sectional  Anatomy  of  Labour  within  the  reach  of  students. 

Another  plate  has  been  added  giving  the  most  recent  Sections,  by  Winter 
and  Saexinger,  which  brings  the  series  up  to  date. 
EDINBURGH,  April  18S9. 

INDEX  OF  PLATES. 

Plate     I.  SHOWING  THE  SECTIONS  published  up  to  the  end  of  1887  by  other  observers  ;  made  before 

and  during  labour,  and  after  delivery. 
,,      II.  VERTICAL  MESIAL  SECTION  of  a  Vl.-para,  who  died  at  the  commencement  of  the  First 

Stage  of  Labour  from  acute  enteritis. 

„     III.  OUTLINE  DIAGRAM,  showing  direction  of  Sections  in  Pis.  IV.,  V.,  and  VI. 
,,     IV.  FIG.  1.    TRANSVERSE  SECTION  along  the  plane  a  6  in  PI.  III.,  and  passing  through  the 

4th  lumbar  vertebra. 
FIG.  2.     TRANSVERSE  SECTION  of  Posterior  half  of  Pelvis  (from  the  same  case  as  Fig.  1) 

along  the  plane  c  d  in  PI.  III.,  passing  through  the  junction  of  the  upper  and  middle 

thirds  of  the  second  sacral  vertebra. 
„      V.  FIG.  1.    AXIAL  CORONAL  SECTION  OF  RIGHT  HALF  OF  PELVIS  along  plane  2  in  PI.  III. ; 

and  passing  through  horizontal  ramns  of  pubes  just  behind  the  obturator  foramen,  and 

through  the  tuberosity  of  the  ischium. 
FIG.  2.     AXIAL  CORONAL  SECTION  OF  RIGHT  HALF  OF  PELVIS  along  plane  4  in  PI.  III.  ; 

and  passing  through  the  anterior-inferior  iliac  spine,  and  posterior  part  of  acetabulmn. 
,,     VI.  FIG.  1.    AXIAL  CORONAL  SECTION  OF  PELVIS,  along  plane  5  in  PI.  III.,  and  passing 

through  the  transverse  diameter  and  axis  of  the  brim. 
FIG.  2.    AXIAL  CORONAL  SECTION  OF  PIGHT  HALF  OF  PELVIS  along  plane  3  in  PI.  III.,  and 

passing  through  the  acetabulum  and  iechial  tuberosity. 
„    VII.  SECTIONS  OF  UTERI,  SPIRIT-HARDENED,  FROM  CASES  OF  PORRO'S  OPKRATION,  bringing  out 

anatomical  facts  in  the  relation  of  the  placenta  to  its  site  of  significance  with  regard  to 

the  mechanism  of  the  III. -Stage. 

,,  VIII.  SECTIONS  FROM  A  FOURTH  CASE  OF  PORRO'S  OPERATION. 
,,    IX.  FIG.  1.    VERTICAL   MESIAL   SECTION   FROM    A   CASE   OF   PARTIAL    PLACENTA    PR^EVIA 

delivered  in  articulo  mortis  by  turning. 
FIG.  2.     VERTICAL  MESIAL  SECTION  FROM  A  CASE  OF  ECLAMPSIA,  delivered  in  articulo 

mortis  by  forceps. 
,,      X.  FIG.  1.    VERTICAL  MESIAL  SECTION  (FROZEN)  OF  PELVIS  with.-Post -Partum  Uterus. 

FIG.  2.    VERTICAL  MESIAL  SECTION  OF  UTERUS  thirty-six  hours  after  delivery. 
,,     XI.  SECTION  OF  I. -PARA,  who  died  five  and  a  half  days  after  delivery. 
„   XII.  SECTIONS  published  during  1888. 


W.  &  A.  K.  JOHNSTON,  EDINBURGH  AND  LONDON. 


With  Illustrations,  price  5s. 


THE    ANATOMY    OF    LABOUR 

AS    STUDIED    IN    FROZEN    SECTIONS, 

AND  ITS  BEARING  ON  CLINICAL  WORK. 

BY 

A.  H.  F.  BARBOUR,  M.A.,  B.Sc.,  M.D.,  F.R.C.P.E.,  F.R.S.E., 

Lecturer  on  Midwifery  and  Diseases  of  Women,  School  of  Medicine,  Edinburgh  ; 

Assistant  Physician  for  Diseases  of  Women  to  the  Royal  Infirmary  ;  Assistant  Physician 

to  the  Royal  Maternity  Hospital ;  Physician  to  the  Women's  Dispensary  ; 

Corresponding  Fellow  of  the  Royal  Academy  of  Medicine,  Turin. 

PREFACE. 

THE  following  pages  were  primarily  intended  as  a  Handbook  to  my 
Atlas  of  the  Anatomy  of  Labour.  They  gather  up,  however,  results 
obtained  from  study  of  all  the  sections  hitherto  published;  and,  to 
bring  these  within  the  reach  of  a  larger  number  of  readers,  this  little 
book  has  been  made  as  far  as  possible  complete  in  itself. 

The  book  falls  into  two  parts.  The  first  of  these  gives,  along  with 
the  description  of  my  own  sections,  the  general  results,  thrown  into  a 
connected  form,  of  all  the  work  that  has  been  done  in  this  department ; 
while  the  second  part  gives  the  Literature  of  the  subject  arranged  so  as 
to  exhibit  in  full  detail  the  observations  of  others. 


TABLE     OF     CONTENTS. 

PART.    I. 

CHAP.      I.    INTRODUCTORY  —  SECTIONAL  ANA-  I  CHAP.  III.   FIRST  STAGE  OF  LABOUR. 

TOMY       AND      ITS      BEARING      ON      CHAP.     IV.     SECOND  STAGE   OF   LABOUR. 


CLINICAL  WORK. 
CHAP.    II.    BEFORE  LABOUR. 


CHAP.     V.   THIRD  STAGE  OF  LABOUR. 

CHAP.   VI.   AFTER  LABOUR:  THE  PUERPERIUM. 


PART   II. 

THE  LITERATI-RE  OF  SECTIONAL  ANATOMY  ARRANGED  CHRONOLOGICALLY. 


Full-Bound  Cloth,  price  15s. 

SPINAL    DEFORMITY 

IN  RELATION  TO  OBSTETRICS, 

BY 

A.  H.  F.  BARBOUR,  M.A.,  B.Sc.,  M.D.,  F.R.C.P.E.,  F.R.S.E., 

Lecturer  on  Midwifery  and  Diseases  of  Women,  School  of  Medicine,  Edinburgh ; 

Assistant  Physician  for  Diseases  of  Women  to  the  Royal  Infirmary ;  Assistant  Physician 

to  the  Royal  Maternity  Hospital ;  Physician  to  the  Women's  Dispensary ; 

Corresponding  Fellow  of  the  Royal  Academy  of  Medicine,  Turin. 

CONSISTING   OF 

39  IMPERIAL  4xo  PLATES  AXD  LETTERPRESS. 

Plates  I. -XXII.  Re-production  ad  naturam  of  Pelvis  and  of  Skeleton  from  cases  of 

Antero-posterior  and  of  Lateral  Curvature. 

Plates  XXIII.-XXXIV.,  and  Apper  dix.    Frozen  Sections  from  two  cases  of 

Caries  of  the  Spine. 


W.  &  A.  K.  JOHNSTON,  EDINBURGH  AND  LONDON. 


LIST    OF 

MEDICAL  AND  SCIENTIFIC  WORKS 

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Lecturer  on  Midwifery  and  Diseases  af  Women,  School  of  Medicine,  Edinburgh. 

This  forms  a  supplement  to  Dr  Berry  Hart's  Atlas  of  Female  Pelvic  Anatomy. 

It  consists  of  twelve  full-sized  or  slightly  reduced  Drawings  of  Frozen  Sections  display- 
ing the  anatomy  of  the  ureters,  ischio-rectal  fossae,  and  levator  ani  muscles,  with  special 
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and  Surgeon  to  the  Edinburgh  Ear  and  Throat  Dispensary. 

The  first  chapters  of  this  Work  treat  of  Diseases  of  the  Ear  in  an  elementary  manner, 
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(3)  Diseases  which  involve  the  Organ  of  Hearing.  Coloured  Lithographs  illustrate  special 
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chapter  coloured  lithographs  of  the  diseased  conditions  described  very  materially  aid 
practitioners  who  desire  to  study  this  branch  without  the  assistance  of  a  teacher. 

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OF  DISEASES  OF  THE  THROAT  AND  LUNGS. 

BY  G.    HUNTER   MACKENZIE,  M.D.,    Edinburgh, 

Lecturer  on  Practical  Laryngology  and  Rhinology  in  the  Extra-Academical  School  of  Medicine, 

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and  to  the  Western  DispeniHiry,  Edinburgh. 


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DISEASES    OF    THE    LARYNX. 

BY  Dr  R.  GOTTSTEIN, 
Lecturer  at  the  University  of  Breslau. 

Translated  and  added  to  by 
P.  M'BRIDE,  M.D.,  F.R.C.P.E.,  F.R.S.E., 

Lecturer  on  Diseases  of  the  Ear  and  Throat,  Edinburgh  School  of  Medicine  • 

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THE  STUDENTS'  ATLAS 

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BONES    AND    LIGAMENTS. 

BY  CHARLES  W.  CATHCART,  M.A.,  M.B.,  F.R.C.S.,  ENG.  AND  EDIN. 

Assistant  Surgeon,  Royal  Infirmary,  Edinburgh,  formerly  Lecturer  on  Anatomy, 

Surgeon's  Hall,  Edinburgh ; 


F.  M.  CAIRD,  M.B.,  F.R.C.S.,  EDINBURGH, 
Senior  Assistant,  Surgical  Department,  University  of  Edinburgh. 


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BY  SIR  WILLIAM  TURNER,  M.B.,  M.R.C.S.,  ENG. 

Professor  of  Anatomy  in  the  University  of  Edinburgh. 

Selected  and  Arranged  under  the  Superintendence  of 

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Plate 

1.  The  Bones. 

2.  The  Ligaments. 

3.  The  Muscles. 

4.  The  Heart  and  Arteries. 


CONTENTS. 
Plate 


5.  Veins  and  Organs  of  Respiration. 

6.  Lymphatics  and  Organs  of  Digestion. 

7.  The  Brain  and  Nerves. 

8.  The  Senses. 


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BY  J.  M 'FAD  YE  AN,  M.B.,  B.Sc., 

Member  of  the  Royal  College  of  Veterinary  Surgeons,  Lecturer  on  Anatomy  at  the 
Royal  (Dick's)  Veterinary  College,  Edinburgh. 


,'<KJ  pp.,  Demy  8ro,  price  lOn. 

THE   COMPARATIVE  ANATOMY 

OF   THE 

DOMESTICATED    ANIMALS. 


Part  I.— OSTEOLOGY  and  ARTHROLOGY. 

WITH  151  ILLUSTRATIONS  IX  THE  TEXT. 


BY  JOHN  M'FADYEAN,  M.B.,  C.M.,  B.Sc., 

Lecturer  on  Anatomy  in  the  Royal  (Dick's)  Veterinary  College,  Edinburgh. 

Published  Quarterly,  price  2s.  Gd.  per  Part ;  Post  free  for  one  year,  10s., 
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A   NEW   VETERINARY   JOURNAL 

ENTITLED 

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Edited  by  J.  M'FADYEAN,  M.B.,  B.Sc.,  Etc. 
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1.  Original  Articles  by  the  most  eminent  British  Veterinarians  relating  to  Anatomy,  Path- 

ology, Medicine,  Surgery,  or  Hygiene. 

2.  Translations  of  important  Articles  from  current  Continental  Veterinary  Literature. 

3.  A  Synopsis  of  the  most,  recent  Discoveries  and  Advances  in  the  domain  of  the  Medical 

Sciences. 

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The  first  Part  was  issued  on  31st  March  1888. 


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Containing  24  Plates  with  423  Coloured  Figures  and  Diagrams,  with  Accompanying 
Text  giving  Arrangement  and  Explanation,  Equivalent  Terms,  Glossary,  and  Classifica- 
tion. 

BT  D.  M' ALPINE,  F.C.S., 

Honourman  of  the  Science  and  Art  Department,  Lecturer  on  Biology  and 
Botany,  etc.,  Edinburgh. 

And  A.  N.  M' ALPINE.  B.Sc., 
(Honours)  London,  Professor  of  Botany  and  Natural  History,  etc.,  Edinburgh. 


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THE    ZOOLOGICAL    ATLAS. 

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ing Text  giving  practical  Directions,  Explanation,  Equivalent  Terms,  etc.,  etc. 

ALSO 

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Containing  16  Full-Coloured  Plates,  with  accompanying  Text,  price  7s.  6d. 
BY  D.  M 'ALPINE,  F.C.S., 

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Natural  History,  Edinburgh. 


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THE     BOTANICAL    ATLAS. 

A  GUIDE  TO  THE  PRACTICAL  STUDY  OF  PLANTS. 

CONTAINING  REPRESENTATIVES  OF  THE  LEADING  FORMS  OF  PLANT  LIFE. 

With  Practical  Directions  and  Explanatory  Text. 
FOR  THE  USE  OF  STUDENTS  IN  MEDICAL  SCHOOLS  AND  UNIVERSITIES. 

BY  D.  M'ALPINE,  F.C.S., 

Lecturer  on  Botany,  Edinburgh  ;  Houourraan  of  the  Science  and  Art  Department ; 
Author  of  a  "Biological  Atlas,"  a  "Zoological  Atlas,"  etc. 

VoL    I.— PHANEROGAMS— 26  Full-coloured  Plates,  with  Explanatory  Text. 
Vol.  II.— CRYPTOGAMS-26  Full-coloured  Plates,  with  Explanatory  Text. 

The  "BOTANICAL  ATLAS"  is  carried  out  on  the  same  plan  as  the  "BIOLOGICAL"  and 
"ZOOLOGICAL"  ATLASES,  which  have  been  so  favourably  received.  There  are  several 
improvements,  however,  introduced,  which  it  is  hoped  the  student  will  appreciate.  The 
colour,  for  instance,  is  natural,  so  that  every  plant,  or  part  of  a  plant,  wears  its  appro- 
priate garb.  The  Life  Histories  of  organisms,  too,  have  received  full  recognition,  and 
the  student  of  Animal  Life  will  thus  see  how  much  there  is  in  common  between  the  two 
kingdoms. 

Originally  Published  in  7  Parts.     Each  Part  contains  6  Plates,  and  is  accompanied  bit  a 
Handbook  in  English.     Price  £1,  Is.  each  Part  icith  Handbook. 

THE    ANATOMICAL    AND 
PHYSIOLOGICAL   ATLAS   OF    BOTANY. 

FOR  USE  IN  SCHOOLS  AND  COLLEGES. 

IN  42  COLOURED  PLATES.     SIZE,  35  BY  25  INCHES. 

BY  DR  ARNOLD  DODEL-PORT, 
Professor  of  Botany  in  the  University  of  Zurich. 

AND 

CAROLINA  DODEL-PORT. 

TEXT  TRANSLATED  BY  D.  M'ALPINE,  F.C.S., 

Lecturer  on  Botany,  Edinburgh. 

PART  I. — Salvia  Sclarea  (Sage).  Cosmarium  Botrytis  (a  Desmid).  Volvox  Globator 
(a  Spherical  Alga).  Mucor  Mucedo  (Common  Brown  Mould).  Drosera  Rotundifolia 
(Round-leaved  Sun-dew).  Ophrys  Arachnites  (on  Orchid). 

PART  II. — Out  of  print. 

PART  III. — Out  of  print. 

PART  IV.— Equisetum  'Telmateia,  Ehrh.  Selaginella  Helvetica,  Spr.  Polytrichum 
Gracile,  Menz.  Volvux  Minor,  Stein.  Passiflora.  Narcissus  Poeticus,  L. 

PART  V.— Chara  Fragilis,  A.  Braun.  Cydonia  Vulgaris,  Pers.  Taxus  Baccata,  L. 
Oedogonium  Diplandrum,  Juranyi.  Centaurea  Cyanus,  L.  Marchantia  Polymorpha,  L. 

PART  VI.— Endocarpon  Pusillum,  Hedw.  Erythrotis  Beddomei,  Hooker  f.  Elodea 
Oanadensis,  Caspary.  Phaseolus  Coccineus,  L.  Cuscuta  Glomerata,  Choisy.  Peziza. 

PART  VII.—  Lava tera  Trimestris,  Fol.  B.  Lavatera  Trimestris,  Fol.  A.  Pinus 
Laricio,  Fol.  C.  Cystosira  Barbata,  J.  AG.  Datura  Stramonium,  L.  Marchantia 
(Archegonium  and  Antheridium). 


W.    &    A.    K.    JOHNSTON, 
EDINA  WORKS,  EASTER  ROAD,  EDINBURGH; 


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